Predictors of Long-Term Opioid Use Among Patients With Painful Lumbar Spine Conditions

Our objective was to assess predictors of self-reported opioid use among patients with back pain due to lumbar disc herniation or spinal stenosis. Data were from the Spine Patient Outcomes Research Trial (SPORT), a multi-site observational study and randomized trial. We examined characteristics shown or hypothesized to be associated with opioid use. Using generalized estimating equations, we modeled associations of each potential predictor with opioid use at 12 and 24 months. At baseline, 42% of participants reported opioid use. Of these participants, 25% reported continued use at 12 months and 21% reported use at 24 months. In adjusted models, smoking (RR = 1.9, P < .001 at 12 months; RR = 1.5, P = .043 at 24 months) and nonsurgical treatment (RR = 1.7, P < .001 at 12 months; RR = 1.8, P = .003 at 24 months) predicted long-term opioid continuation. Among participants not using opioids at baseline, incident use was reported by 8% at 12 months and 7% at 24 months. We found no significant predictors of incident use at 12 or 24 months in the main models. In conclusion, nonsurgical treatment and smoking independently predicted long-term continued opioid use. To our knowledge, this is the first longitudinal study to assess predictors of long-term and incident opioid use among patients with lumbar spine conditions.PerspectiveThis longitudinal study of patients with disc herniation or spinal stenosis found that nonsurgical treatment and smoking predicted long-term self-reported opioid use. The greater risk of opioid continuation with nonsurgical therapy may be helpful in decision-making about treatment. The relationship between opioid use, smoking, and other substance use deserves further study.     

A cost-effectiveness analysis of universal versus selective immunization with Mycobacterium bovis bacille Calmette-Guérin in Finland.

SETTING: Mycobacterium bovis bacille Calmette-Gue?in (BCG) is provided to all infants born in Finland. OBJECTIVE: To analyze the cost-effectiveness of universal versus selective BCG immunization. DESIGN: A Markov model was developed to simulate rates of tuberculosis (TB) and non-tuberculous mycobacterial disease (NTM), and to examine the cost-effectiveness in terms of cost per case averted of three different strategies: universal BCG, selective BCG (10% of infants at higher TB risk than other infants) or no BCG immunization. RESULTS: In a cohort of 60,000 infants over 15 years, the model predicts five cases each of TB and NTM disease with universal immunization, 8-21 TB and 31 NTM cases with various strategies of selective immunization, and 25 TB and 34 NTM cases with no BCG immunization. BCG side-effects are predicted in 5, 0.5 and 0 infants, respectively. The cost per case averted for immunization strategies ranges from a cost of 38,311 US dollars to a savings of 323 dollars as selective immunization becomes more efficient at targeting infants at highest risk of TB. CONCLUSIONS: In a country with a low incidence of pediatric tuberculosis, selective BCG immunization is a more cost-effective strategy than universal BCG immunization for the prevention of tuberculosis, but results in an increase in NTM cases.     

Glioblastoma multiforme treatment with clinical trials for surgical resection (aminolevulinic acid)

5-Aminolevulinic acid (5-ALA)-induced tumor fluorescence can be used to identify tissue for resection using an adapted operating microscope. A multi-institutional clinical trial comparing fluorescence-guided versus white light tumor resection reported significant improvement in completeness of resection and 6-month progression-free survival. The degree of 5-ALA-induced fluorescence correlates with histopathologic grade of tumor, degree of tumor cell infiltration, and proliferation indices. Quantitative methodologies for assessment of tissue fluorescence have significantly improved the ability to detect tumor tissue and intraoperative diagnostic performance. These developments extend the applicability of this technology to additional tumor histologies and provide the rationale for further instrumentation development.     

Report of the NIH Task Force on Research Standards for Chronic Low Back Pain

Despite rapidly increasing intervention, functional disability due to chronic low back pain (cLBP) has increased in recent decades. We often cannot identify mechanisms to explain the major negative impact cLBP has on patients' lives. Such cLBP is often termed non-specific and may be due to multiple biologic and behavioral etiologies. Researchers use varied inclusion criteria, definitions, baseline assessments, and outcome measures, which impede comparisons and consensus. Therefore, NIH Pain Consortium charged a Research Task Force (RTF) to draft standards for research on cLBP. The resulting multidisciplinary panel recommended using 2 questions to define cLBP; classifying cLBP by its impact (defined by pain intensity, pain interference, and physical function); use of a minimum dataset to describe research participants (drawing heavily on the PROMIS methodology); reporting “responder analyses” in addition to mean outcome scores; and suggestions for future research and dissemination. The Pain Consortium has approved the recommendations, which investigators should incorporate into NIH grant proposals. The RTF believes that these recommendations will advance the field, help to resolve controversies, and facilitate future research addressing the genomic, neurologic, and other mechanistic substrates of chronic low back pain. We expect that the RTF recommendations will become a dynamic document and undergo continual improvement.PerspectiveA task force was convened by the NIH Pain Consortium with the goal of developing research standards for chronic low back pain. The results included recommendations for definitions, a minimum dataset, reporting outcomes, and future research. Greater consistency in reporting should facilitate comparisons among studies and the development of phenotypes.     

Cost effectiveness of screening perimenopausal white women for osteoporosis: bone densitometry and hormone replacement therapy

Bone mass measurement at menopause to identify and selectively prescribe hormone replacement therapy for women at high risk for fractures has seen limited clinical use. We used epidemiologic, clinical, and economic data in a decision-analytic model to compare the following clinical strategies for perimenopausal, asymptomatic, white women with intact uteri: no intervention; bone mineral density measurement followed by selective, long-term (15-year) estrogen-progestin therapy in women with low bone mass; and unselective, universal hormone replacement therapy. Life expectancy and direct medical cost per patient were estimated for each strategy. Strategies for screening and treating women with perimenopausal bone mineral density less than 0.9 g/cm2 or less than 1.0 g/cm2 would cost $11,700 or $22,100, respectively, per year of additional life gained. If the cost of screening is less than $84, then resource savings from hip fractures prevented would be more than the cost of screening and treatment. Universal treatment without screening would prevent additional fatal fractures but would expose many more women to the adverse effects of hormone replacement therapy and would cost an additional $349,000 per year of life gained compared with the screening strategies. When quality of life was considered, screening was found to be cost effective over a wide range of assumptions. The choice between universal treatment and screening depends on the risks (breast cancer), perceived side effects (menstrual bleeding), and benefits (prevention of ischemic heart disease) of estrogen-progestin therapy. We conclude that screening asymptomatic, perimenopausal white women to detect low bone mass and to target hormone replacement therapy at women who are at the greatest risk for fracture is a reasonably cost-effective use of health care resources. However, cost-effective screening guidelines cannot be explicitly established until further data addressing the association between bone mass measurements in the hip and hip fracture risk are available.     

Differential effect of phorbol esters and interleukin-3 on protein kinase C isoform content and kinase activity in the FDC-P1 cell line

FD/PMA is a subclone of the interleukin-3 (IL-3)-dependent, FDC-P1 cell line, which proliferates in response to either 12-O- tetradecanoylphorbol-13 acetate (PMA) or IL-3. While several endogenous substrates were phosphorylated in response to protein kinase C (PKC) activation in FDC-P1, phospholipid-dependent phosphorylation in the FD/PMA grown in PMA was not observed. Basal, phosphatidylserine- independent, and diolein-independent phosphorylation of cytosolic substrates with molecular weights of 17, 52, 57, and 105 Kd were enhanced in FD/PMA cells grown in PMA as compared with FDC-P1 cells cultured in IL-3. Phosphorylation of a 105-Kd substrate was enhanced in the particulate fraction of FD/PMA cells maintained in PMA. The 17-Kd substrate in FD/PMA cells comigrated with a substrate phosphorylated in a PKC-dependent manner in FDC-P1 cells. Phosphorylation of the 52- and 57-Kd substrates, but not of the 17-Kd substrate, was inhibited by H-7 and staurosporine. A portion of the PMA-induced cytosolic kinase activity coeluted with PKC on diethyl aminoethyl chromatography. While FD/PMA cells cultured in PMA contained negligible PKC-dependent phosphorylation of endogenous substrates or histone, alpha and epsilon PKC isoforms were detected by Western blot analysis. PKC phosphotransferase activity was observed in FD/PMA cells grown in PMA when peptides corresponding to residues 720 to 737 of PKC-epsilon or residues 4 to 14 of myelin basic protein were used as substrates. These data indicate that maintenance of FD/PMA cells in PMA stimulates proliferation and markedly alters PKC substrate specificity. Generation of at least two phospholipid-independent kinases occurs in PMA-treated cells.     

Acute lower respiratory illness in childhood as a predictor of lung function and chronic respiratory symptoms

This study investigated the relationship of acute lower respiratory illness (LRI) to level and change in level of forced expiratory volumes in a cohort of 801 children, followed longitudinally for a maximum of 13 yr. The co-occurrence of respiratory illness before 2 yr of age and two or more LRI during a single surveillance year was associated with a 20.3% lower mean cross-sectional level of FEF25-75, and with reduced longitudinal change in level of FEF25-75. The effect of LRI on lung function was uniformly stronger for boys than for girls. Of the children with illness before 2 yr of age and two or more LRI, six of 14 were male asthmatics with mean levels of FEF25-75 that were lower than those of other asthmatic children. Pneumonia and/or hospitalization for respiratory illness prior to the onset of study were associated with lower cross-sectional levels of forced expiratory volumes at entry to the study, even when asthmatics/persistent wheezers were eliminated from the analysis (6.1% lower level of FEV1 for a nonasthmatic boy with previous hospitalization versus a nonasthmatic boy without hospitalization). In the longitudinal analysis, pneumonia and/or hospitalization were associated with slower increase in level of forced expiratory volumes, even after adjusting for "ever diagnosis of asthma/current any wheeze" (starting at the same leve, after eight years a boy with hospitalization would develop a 5.0% lower FEV1 than a boy without hospitalization). Acute LRI also was evaluated as a predictor of chronic respiratory symptoms.(ABSTRACT TRUNCATED AT 250 WORDS)