The psychological burden of disease among patients undergoing cervical spine surgery: Are we underestimating our patients' inherent disability?

BACKGROUND: Studies have utilized psychological questionnaires to identify the psychological distress among certain surgical populations. RESEARCH QUESTION: Is there an additional psychological burden among patients undergoing surgical treatment for their symptomatic degenerative cervical disease? MATERIALS AND METHODS: Patients>18 years of age with symptomatic, degenerative cervical spine disease were included and prospectively enrolled. Correlations and multivariable logistic regression analysis assessed the relationship between these mental health components (PCS, FABQ) and the severity of disability described by the NDI, EQ-5D, and mJOA score. Patient distress scores were compared to previously published benchmarks for other diagnoses. RESULTS: 47 patients were enrolled (age: 56.0 years,BMI: 29.7kg/m2). Increasing neck disability and decreasing EQ-5D were correlated with greater PCS and FABQ(all P<0.001). Patients with severe psychological distress at baseline were more likely to report severe neck disability, while physician-reported mJOA had weaker associations. Compared to historical controls of lumbar patients, patients in our study had greater levels of psychological distress, as measured by FABQ (40.0 vs. 17.6; P<0.001) and PCS (27.4 vs. 19.3;P<0.001). DISCUSSION AND CONCLUSION: Degenerative cervical spine patients seeking surgery were found to have a significant level of psychological distress, with a large portion reporting severe fear avoidance beliefs and catastrophizing pain at baseline. Strong correlation was seen between patient-reported functional metrics, but less so with physician-reported signs and symptoms. Additionally, this population demonstrated higher psychological burden in certain respects than previously identified benchmarks of patients with other disorders. Preoperative treatment to help mitigate this distress, impact postoperative outcomes, and should be further investigated. LEVEL OF EVIDENCE: Level III.

Comparison of treatment adherence outcome among PLHIV enrolled in economic strengthening program with community control.

Economic strengthening (ES) interventions are increasingly promoted to support the economic well-being and food security of people living with HIV (PLHIV) in resource poor settings. This study aims to assess the impact of ES interventions in Ethiopia designed to address poverty and food insecurity on antiretroviral treatment (ART) adherence. A comparative cross-sectional design was employed to compare treatment adherence between food insecure PLHIV benefitting from the ES project of WFP Ethiopia to food insecure PLHIV not participating in ES. Using the visual analogue scale (VAS) to measure ART adherence, only 9.9% of the ES group reported less than 95% adherence compared to 25.9% of the comparison group. Controlling for socio-economic and demographic variables using logistic regression models, engagement in ES activities increased the likelihood of having 95% or greater ART adherence by a factor of 2.4 and 5.6 respectively (as measured by VAS and ACTG approaches) compared to those PLHIV that were not engaged in ES. The findings of the study suggest that engagement in ES contributes to improved ART adherence among food insecure PLHIV. If further studies validate this result, ES should be adopted as a key strategy to improve HIV treatment adherence in resource poor settings where adherence is an issue of concern.

High prevalence of food insecurity among HIV-infected individuals receiving HAART in a resource-rich setting.

This study aimed to assess the prevalence and correlates of food insecurity in a cohort of HIV-infected individuals on highly active antiretroviral therapy (HAART) in British Columbia (BC), Canada. Adults receiving HAART voluntarily enrolled into the Longitudinal Investigations into Supportive and Ancillary Health Services (LISA) cohort. Individual food insecurity was measured using a modified version of the Radimer/Cornell Questionnaire. We performed bivariate analyses to determine differences between explanatory variables for individuals who were food secure and food insecure. We performed logistic regression to determine independent predictors of food insecurity. Of the 457 individuals enrolled in the LISA cohort, 324 (71.0%) were found to be food insecure. Multivariate analysis indicated that individuals who had an annual incomes less than $15,000 (odds ratio [OR] 3.15, 95% confidence interval [CI] 1.83, 5.44), used illicit drugs (OR 1.85, 95% CI 1.03, 3.33), smoked tobacco (OR 2.30, 95% CI 1.30, 4.07), had depressive symptoms (OR 2.34, 95% CI 1.38, 3.96), and were younger (OR 0.95, 95% CI, 0.92, 0.98) were more likely to be food insecure. Our results demonstrated a high (71%) prevalence of food insecurity among HIV-infected individuals receiving HAART in this resource-rich setting, and that food insecurity is associated with a compendium of environmental and behavioral factors. More research is needed to understand the biological and social pathways linking food insecurity to these variables in order to identify program strategies that can effectively improve food security among HIV-infected populations.

Spin-orbit coupling in ferromagnetic nickel.

We use the Gutzwiller variational theory to investigate the electronic and magnetic properties of fcc nickel. Our particular focus is on the effects of the spin-orbit coupling. Unlike standard relativistic band-structure theories, we reproduce the experimental magnetic-moment direction and we explain the change of the Fermi-surface topology that occurs when the magnetic-moment direction is rotated by an external magnetic field. The Fermi surface in our calculation deviates from early de Haas-van Alphen results. We attribute these discrepancies to an incorrect interpretation of the raw de Haas-van Alphen data.

Effects of HIV-related stigma among an early sample of patients receiving antiretroviral therapy in Botswana.

Botswana, with its estimated HIV prevalence of 37%, instituted a policy of universal access to antiretroviral therapy (ART) in 2002. Initial enrolment lagged behind expectations, with a shortfall in voluntary testing that observers have attributed to HIV-related stigma - although there are no published data on stigma among HIV-positive individuals in Botswana. We interviewed 112 patients receiving ART in 2000, finding evidence of pervasive stigma in patterns of disclosure, social sequelae, and delays in HIV testing. Ninety-four percent of patients reported keeping their HIV status secret from their community, while 69% withheld this information even from their family. Twenty-seven percent of patients said that they feared loss of employment as a result of their HIV status. Forty percent of patients reported that they delayed getting tested for HIV; of these, 51% cited fear of a positive test result as the primary reason for delay in seeking treatment, which was often due to HIV-related stigma. These findings suggest that success of large-scale national ART programmes will require initiatives targeting stigma and its social, economic and political correlates.

Medicine betrayed: hemophilia patients and HIV in the US.

The contamination of blood products by HIV in the early 1980s resulted in thousands of deaths among people with hemophilia in the United States and elsewhere. In the US, industry, government, physicians, and advocacy groups were implicated in this tragedy. In response to pleas from members of the US hemophilia community, the Institute of Medicine (IOM) of the National Academy of Science convened a public hearing to identify the institutional determinants of the HIV/AIDS epidemic among US hemophilia patients. The resulting IOM Report (1995) established a narrative of the crisis and indicated necessary improvements to the management of the US blood supply. The Report, however, failed to address the hemophilia community's demands for accountability and retribution. In this paper we explore the moral and social dimensions of this tragedy through narrative analysis of the original testimonies of hemophilia sufferers, interviews with some patients and their families, and a re-examination of the text of the IOM Report itself. We examine the process by which this crisis was addressed--through the discourses of science and law--and how it was ultimately framed as a failure of management and oversight rather than a moral failure of the for-profit health-care system. Thus, while the Report and its aftermath demonstrate powerfully how testimonials of suffering can influence public policy, by not addressing what is at stake for the victims--failure to protect patients in an era of increasingly commodified health care--it led to an exculpatory solution that obfuscated the moral dimensions of suffering.

Approaches to improve the outcome of patients with delayed recovery.

The purpose of this chapter is to promote a model to prevent chronicity and disability from non-specific low back pain (NSLBP). Delayed recovery is defined in this chapter as the period between 4 and 8 weeks after onset of NSLBP during which a patient has not yet returned to work. The recognition of predictors associated with delayed recovery at onset of the problem helps health care providers in their treatment plan. An algorithm can be useful for health care providers and employers in guiding the employee back to work. A multidisciplinary return to work programme is an essential part of the algorithm.

Low back pain assessment training of industry-based physicians.

We have developed an educational program to train industry-based physicians in a new low back pain assessment procedure based on the recommendation of The Clinical Practice Guidelines on Acute Low Back Pain Problems in Adults published by the Agency for Health Care Policy and Research, U.S. Department of Health and Human Services. The clinical classification system based on the findings from the Quebec Task Force was used to categorize the subjects. The educational program included group and individual sessions with an extensive period of active follow-up. Protocol compliance was measured through a computer-based surveillance system that monitored evaluation form completion. The results showed significant change (p < 0.001) in physician compliance in completing a standardized examination following an administrative mandate to change. Little change in clinical practice was recorded with an educational training program only. Further research into the factors responsible for the results is suggested.

Physical exercise and low back pain.

Health care providers often prescribe exercises as treatment for nonspecific low back pain. However, the effectiveness of this treatment is poorly documented in the literature. While the evidence suggests that exercise in general is beneficial, there is a lack of knowledge about the types, frequency and duration of exercises that should be prescribed and at what stage of injury they are most helpful. In addition, few studies have dealt with exercise treatment alone rather than in combination with other treatments, making it hard to decipher the unique contribution of exercise. Inadequate study designs also make conclusions difficult. Conversely, the literature clearly shows that inactivity has detrimental effects (i.e. delayed return to normal activity, and negative physiological and psychological effects) for low back pain patients.

Stimulation of rat striatal tyrosine hydroxylase activity following intranigral administration of sigma receptor ligands.

The effects of sigma ligands on turning behavior and striatal tyrosine hydroxylase activity were determined following microinjection of two chemically dissimilar sigma ligands into the rat substantia nigra. Striatal tyrosine hydroxylase activity was monitored by measuring the amount of 3,4-dihydroxyphenylalanine (DOPA) formed following inhibition of DOPA decarboxylase activity with m-hydroxybenzylhydrazine (NSD-1015). The sigma ligands, 1,3-di-o-tolylguanidine (DTG) and (-)-deoxy-N-benzylnormetazocine, produced a significant increase both in contralateral turning and in tyrosine hydroxylase activity. The DTG-induced increase in tyrosine hydroxylase activity was not antagonized by intranigral injection of the NMDA receptor antagonist, 3-(2-carboxypiperazine-4-yl)-propyl-1-phosphonic acid (CPP). CPP alone produced significant contralateral turning that was not accompanied by an increase in striatal tyrosine hydroxylase activity, indicating that turning per se is not sufficient to activate striatal tyrosine hydroxylase. The DTG-induced increase in tyrosine hydroxylase activity was antagonized by general anesthetics such as halothane and chloral hydrate. These results indicate that occupancy of sigma receptors in the substantia nigra is associated with an activation of dopamine formation in dopaminergic terminals in the striatum and support the concept that sigma activity in the substantia nigra produces an activation of dopamine-mediated responses in the striatum.

Renal Ca2+ + Mg2+ ATPase in congestive heart failure due to diabetes.

The authors have previously shown that atrial natriuretic peptide (ANP) mediates its cellular effects in part by changes in Ca2+ homeostasis in kidney cortex and that Ca2+ + Mg2+ ATPase is linked to ANP receptors, being reciprocally modulated by the guanylate cyclase system. The present study was designed to examine the status of this coupling in diabetes-induced congestive heart failure and the effect of its alterations on the functional integrity of the renal cell. Ca2+ + Mg2+ ATPase and guanylate cyclase were tested in hypertensive-diabetic rats (D + H), which develop congestive heart failure (CHF) at ten weeks following streptozotocin (65 mg/kg) injection and abdominal aortic constriction. The ATPase activity was measured by the release of 32P from [gamma-32P]ATP in the medium. While the guanylate cyclase activity was decreased very rapidly in the hypertensive-diabetic group, the sensitivity of the Ca2+ pump to ANP was increased at an early stage (three weeks) and decreased at a late stage (ten weeks) of CHF. The authors conclude that a defect in coupling between the Ca2+ pump and the ANP-receptor system as observed in the D + H group may contribute to the development of nephropathy and CHF.

Psychosocial issues in the prevention of chronic low back pain--a literature review.

This chapter has reviewed research on psychological and social factors associated with the onset and progression of low back pain. From this review it can be concluded that psychosocial traits appear to be important contributors to the course of pain and disability though methodologically well-designed longitudinal studies are rare. For this reason it is difficult to assess the relative importance of, for example, psychological distress compared with work stress. Furthermore, the mechanisms by which specific variables effect back pain remain unknown. The answer, no doubt, lies in longitudinal studies which employ multicausal models. It has been noted the psychosocial treatments which have proven effective for chronic pain populations are rarely assessed with acute pain patients. Some problems are the inaccessibility of acute back pain sufferers to psychologists, the difficulty of isolating the effect of one component of a multidisciplinary programme and the lack of uniform practice of psychosocial techniques. None the less, programmes which include psychosocial interventions appear to have superior results to those which do not. Since these techniques are often simple and inexpensive to include they should be incorporated into all treatment programmes where the potential for chronic pain syndrome exists. Gaps and flaws in current research methodologies have been identified and suggestions for future investigations have been proposed. In addition we have attempted to provide some practical guidelines for health care professionals to help them identify salient psychosocial issues which may effect the course of their patient's treatment. Recommendations for assessment and referral are also provided.

The psychological impact of idiopathic scoliosis on the adolescent female. A preliminary multi-center study.

Seventy-two female idiopathic scoliosis patients, ages 12 to 16, who were receiving either no treatment/observation, the Scolitron, a brace, or who had undergone surgery were tested to determine the psychological impact of scoliosis. Mothers of the patients also served as subjects. A normal group of adolescents served as control subjects. Results showed that all groups were less likely to feel that their health status was due to chance than the controls. No other psychological differences were found between treatment groups, which contradicts previous reports of greater psychological distress among brace patients as compared with Scolitron (TM) patients. It was found that mothers' attitudes toward their children's illnesses were strongly and positively related to their children's attitudes toward their illnesses, and that these attitudes were strongly correlated with psychological distress. These findings underscore the need to consider the parent-child relationship when treating the adolescent patient.

Adolescent health care: perceptions and needs of the practicing physician.

Three hundred thirty-one Indiana physicians practicing general-family medicine (GP-FP), obstetrics-gynecology (OB-GYN), pediatrics (PED), internal medicine (IM), and psychiatry (PSYCH) were surveyed as to their perceptions about adolescent health and their perceived need for specific adolescent services and Continuing Medical Education (CME). Significant differences were noted in all specialty areas that were not accounted for by the sex or age of the physician. The majority of GP-FP and PED reported that adolescents (aged 11-19 years) made up at least 10% of their practice compared to fewer than 5% of IM practices. Fewer than 7% of the respondents had had no training about adolescent medicine; most (47.5%) had received some CME in adolescent medicine. Family planning was the service least likely to be: provided by PED, IM, and PSYCH, (p less than 0.0001); considered serious for these physicians' adolescent patients (p less than 0.0001); and of interest for CME by all physicians (p less than 0.0001). All specialities believed their adolescent patients to be minimally troubled by the most common problems of youth (p less than 0.0001), but did accurately perceive youth as having psychosocial and medical problems. Training about substance abuse, counseling, learning problems, and eating disorders were most desired. Few respondents wanted individualized, in-person training. The implications of these results are discussed.

Lateral electrical surface stimulation (LESS) compliance in adolescent female scoliosis patients.

This retrospective study of lateral electrical surface stimulation (LESS) treatment for patients with progressive idiopathic scoliosis was performed to document patient compliance in the standard electrical stimulation program and to gain objective data to perform a relative comparison of electrical stimulation and bracing compliance. Forty mothers of adolescent female patients participating in the electrical stimulation program of one of the authors (NK) were interviewed confidentially by an independent observer (SW). Patients whose compliance was rated good or total were thought to have acceptable compliance rates. Overall, 50% showed good or total compliance, 10% fair, 5% poor, and 35% failures. It appeared that the failures tended to exaggerate their symptoms and use "skin irritation" as an excuse to discontinue treatment. The longer patients used the LESS (scolitron) device, the more compliant they became (P less than 0.0). This is opposite to the findings about brace compliance. Confidence of the mother in the device showed a positive correlation (P less than 0.008) with compliance, and a mother's concern of how others would react to her child's scoliosis had a negative correlation (P less than 0.003). From the results of this study, overall compliance appears to be somewhat better for electrical stimulation programs than for bracing programs. However, the high failure rate was both disappointing and surprising.