The 3-item pain intensity (P), interference with the enjoyment of life (E), and interference with general activity (G), or PEG, has become one of the most widely used measures of pain severity and ...interference. The minimally important differences (MID) and responsiveness of the PEG are essential metrics for solidifying its role in research and clinical care. The current study aims to establish the MID and responsiveness of the PEG by synthesizing data from 1,710 participants across 6 controlled trials. MIDs were estimated using absolute score changes among individuals reporting their pain was "a little better" on a retrospective global change anchor as well as distribution-based estimates using standard deviation thresholds and 1 and 2 standard errors of measurement. Responsiveness was assessed using standardized response means, area under the curve, and treatment effect sizes. MID estimates for the PEG ranged from 0.60 to 1.1 when using 0.35 SD, and 0.78 to 1.22 using 1 standard error of measurement. MID estimates using the global anchor had somewhat more variability but most estimates ranged from 1.0 to 1.75. Responsiveness effect sizes were generally large (>.80) for standardized response means and moderate (>.50) for treatment effect. Similarly, the most area under the curve values demonstrated an acceptable level of scale responsiveness (≥.70). Importantly, MID estimates and responsiveness of the PEG and BPI scales were largely comparable when aggregating data across trials. Our synthesis indicates that 1 point is a reasonable MID estimate on these 0- to 10-point pain scales, with 2 points being an upper bound. PERSPECTIVE: This article synthesizes data from 6 clinical trials to establish the minimally important difference (MID) and responsiveness of the 3-item PEG pain scale. The PEG demonstrated good responsiveness, and 1 to 2 points proved to be reasonable estimates for the lower and upper bounds of the MID.
The PTSD Checklist for DSM‐5 (PCL‐5) is a measure of posttraumatic stress disorder (PTSD) symptom severity that is widely used for clinical and research purposes. Although previous work has examined ...metrics of minimal important difference (MID) of the PCL‐5 in veteran samples, no work has identified PCL‐5 MID metrics among adults in primary care in the United States. In this secondary analysis, data were evaluated from primary care patients (N = 971) who screened positive for PTSD and participated in a large clinical trial in federally qualified health centers in three U.S. states. Participants primarily self‐identified as women (70.2%) and White (70.3%). We calculated test–retest reliability using clinic registry data and multiple distribution‐ and anchor‐based metrics of MID using baseline and follow‐up survey data. Test–retest reliability (Pearson's r, Spearman's ρ, intraclass correlation coefficient) ranged from adequate to excellent (.79–.94), with the shortest time lag demonstrating the highest reliability estimate. The MID for the PCL‐5 was estimated using multiple approaches. Distribution‐based approaches indicated an MID range of 8.5–12.5, and anchor‐based approaches indicated an MID range of 9.8–11.7. Taken together, the MID metrics indicate that PCL‐5 change scores of 9–12 likely reflect real change in PTSD symptoms and indicate at least an MID for patients, whereas PCL‐5 change scores of 5 or less likely are not reliable. These findings can help inform clinicians using the PCL‐5 in similar populations to track patient responses to treatment and help researchers interpret PCL‐5 score changes in clinical trials.
To gain mechanistic insights, we compared effects of low fermentable oligosaccharides, disaccharides and monosaccharides and polyols (FODMAP) and high FODMAP diets on symptoms, the metabolome and the ...microbiome of patients with IBS.
We performed a controlled, single blind study of patients with IBS (Rome III criteria) randomised to a low (n=20) or high (n=20) FODMAP diet for 3 weeks. Symptoms were assessed using the IBS symptom severity scoring (IBS-SSS). The metabolome was evaluated using the lactulose breath test (LBT) and metabolic profiling in urine using mass spectrometry. Stool microbiota composition was analysed by 16S rRNA gene profiling.
Thirty-seven patients (19 low FODMAP; 18 high FODMAP) completed the 3-week diet. The IBS-SSS was reduced in the low FODMAP diet group (p<0.001) but not the high FODMAP group. LBTs showed a minor decrease in H
production in the low FODMAP compared with the high FODMAP group. Metabolic profiling of urine showed groups of patients with IBS differed significantly after the diet (p<0.01), with three metabolites (histamine, p-hydroxybenzoic acid, azelaic acid) being primarily responsible for discrimination between the two groups. Histamine, a measure of immune activation, was reduced eightfold in the low FODMAP group (p<0.05). Low FODMAP diet increased Actinobacteria richness and diversity, and high FODMAP diet decreased the relative abundance of bacteria involved in gas consumption.
IBS symptoms are linked to FODMAP content and associated with alterations in the metabolome. In subsets of patients, FODMAPs modulate histamine levels and the microbiota, both of which could alter symptoms.
NCT01829932.
Quantifying impacts of ecological disturbance on ecosystem carbon and water fluxes will improve predictive understanding of biosphere-atmosphere feedbacks. Tree mortality caused by mountain pine bark ...beetles (Dendroctonus ponderosae) is hypothesized to decrease photosynthesis and water flux to the atmosphere while increasing respiration at a rate proportional to mortality. This work uses data from an eddy-covariance flux tower in a bark beetle infested lodgepole pine (Pinus contorta) forest to test ecosystem responses during the outbreak. Analyses were conducted on components of carbon (C) and water fluxes in response to disturbance and environmental factors (solar radiation, soil water content and vapor pressure deficit). Maximum CO2 uptake did not change as tree basal area mortality increased from 30 to 78% over three years of beetle disturbance. Growing season evapotranspiration varied among years while ecosystem water use efficiency (the ratio of net CO2 uptake to water vapor loss) did not change. Between 2009 and 2011, canopy water conductance increased from 98.6 to 151.7 mmol H2O m−2 s−1. Ecosystem light use efficiency of photosynthesis increased, with quantum yield increasing by 16% during the outbreak as light increased below the mature tree canopy and illuminated remaining vegetation more. Overall net ecosystem productivity was correlated with water flux and hence water availability. Average weekly ecosystem respiration, derived from light response curves and standard Ameriflux protocols for CO2 flux partitioning into respiration and gross ecosystem productivity, did not change as mortality increased. Separate effects of increased respiration and photosynthesis efficiency largely canceled one another out, presumably due to increased diffuse light in the canopy and soil organic matter decomposition resulting in no change in net CO2 exchange. These results agree with an emerging consensus in the literature demonstrating CO2 and H2O dynamics following large scale disturbance events are dependent not only on tree mortality but also on the remaining and new vegetation responses because mortality and recovery occur at the same time.
Background
Engagement in evidence-based psychotherapy (EBP) among veterans with behavioral health conditions is often low. The Veterans Health Administration (VHA) is implementing a “Whole Health ...(WH)” system of care, to identify veteran personal health goals, align care with those goals, and offer services designed to engage and empower veterans to achieve well-being.
Objective
To examine the relationship between veteran WH utilization and subsequent engagement in EBP.
Design
Retrospective analysis of VHA administrative records from 18 facilities implementing WH.
Subjects
Veterans (
n
= 265,364) with a diagnosis of depression, post-traumatic stress disorder (PTSD), and/or anxiety who had a mental healthcare encounter but no EBP use in fiscal year (FY) 2018. Among this cohort, 33,146 (12.5%) began using WH in FY2019.
Main Measures
We examined use of an EBP for depression, anxiety, and/or PTSD within 1 year of the index date of WH use compared to use of an EBP anytime during FY2019 for veterans not identified as using WH. We used multiple logistic regression to examine the association between veteran WH use and EBP engagement.
Key Results
Approximately 3.0% (
n
= 7,860) of the veterans in our overall cohort engaged in an EBP in the year following their index date. Controlling for key demographic, health, and utilization variables, WH users had 2.4 (95% CI: 2.2–2.5) times higher odds of engaging in an EBP the following year than those with no WH utilization. Associations between utilization of specific WH services (vs. no utilization of that service) and engagement in an EBP in the subsequent year ranged from 1.6 (95% CI: 1.0–2.6) to 3.5 (95% CI: 3.2–3.9) across the different types of WH services used.
Conclusions
WH use was associated with increased engagement in EBPs among veterans with depression, anxiety, and/or PTSD. Future interventions intended to promote veteran engagement in EBPs may benefit from leveraging WH services and therapies.
The gut-brain axis has received increasing attention recently due to evidence that colonic microbes can affect brain function and behavior. However, little is known about the innervation of the colon ...by a major component of the gut-brain axis, vagal afferent neurons. Furthermore, it is currently unknown whether individual NG neurons or DRG neurons innervate both the proximal and distal colon. We aimed to quantify the number of vagal and spinal afferent neurons that innervate the colon; and determine whether these individual neurons simultaneously innervate the mouse proximal and distal colon. C57Bl/6 mice received injections of a combination of retrograde tracers that were either injected into the muscularis externa of the proximal or the distal colon: fast blue, DiI and DiO. Five to seven percent of lumbosacral and thoracolumbar spinal afferent neurons, and 25% of vagal afferent neurons were labelled by injections of DiI and DiO into the colon. We also found that approximately 8% of NG neurons innervate the distal colon. Ten percent of labeled thoracolumbar and 15% of labeled lumbosacral DRG neurons innervate both the distal and proximal colon. Eighteen percent of labeled NG neurons innervated both the distal and proximal colon. In conclusion, vagal afferent innervation of the distal colon is less extensive than the proximal colon, whereas a similar gradient was not observed for the spinal afferent innervation. Furthermore, overlap appears to exist between the receptive fields of vagal and spinal afferent neurons that innervate the proximal and distal colon.
The prevalence of co-occurring chronic pain and posttraumatic stress disorder (PTSD) has yet to be established in a nationally representative sample of US veterans, and little is known about the ...individual contributing roles of these disorders to the psychiatric and functional burden of this comorbidity.
To determine the prevalence of chronic pain, PTSD, and co-occurring chronic pain and PTSD, and psychiatric comorbidities and psychosocial functioning in these groups.
Data were analyzed from the National Health and Resilience in Veterans Study, which surveyed a nationally representative sample of US veterans.
Veterans (n=4069) were classified into four groups: control (i.e., no PTSD or chronic pain), chronic pain only, PTSD only, and co-occurring chronic pain and PTSD.
A probable PTSD diagnosis was established using the PTSD Checklist for DSM-5, and a chronic pain diagnosis using a self-report item that queried health care professional diagnoses. Psychiatric and functional status were assessed using the Patient Health Questionnaire-4, Alcohol Use Disorders Identification Test, Screen of Drug Use, Suicide Behaviors Questionnaire-Revised, Short Form Health Survey-8, Brief Inventory of Psychosocial Functioning, and Medical Outcomes Study Cognitive Functioning Scale.
A total of 3.8% of veterans reported both probable PTSD and a diagnosis of chronic pain. Relative to veterans with chronic pain alone, those with co-occurring chronic pain and probable PTSD were more likely to screen positive for psychiatric disorders (odds ratios ORs=2.59-9.88) and scored lower on measures of psychosocial functioning (Cohen's ds=0.38-1.43). Relative to veterans with probable PTSD only, those with co-occurring chronic pain and probable PTSD were more likely to have attempted suicide (OR=4.79; 95%CI, 1.81-12.69).
Results underscore the importance of whole health care that considers a broad range of health and functional domains in the assessment and treatment of co-occurring chronic pain and PTSD in veterans.
Visceral hypersensitivity, a fundamental mechanism of chronic visceral pain disorders, can result from both central or peripheral factors, or their combination. As an important regulator of normal ...gut function, the gut microbiota has been implicated as a key peripheral factor in the pathophysiology of visceral hypersensitivity. Patients with chronic gastrointestinal disorders, such as irritable bowel syndrome, often present with abdominal pain secondary to adverse reactions to dietary components. As both long- and short-term diets are major determinants of gut microbiota configuration that can result in changes in microbial metabolic output, it is becoming increasingly recognized that diet-microbiota interactions play an important role in the genesis of visceral sensitivity. Changes in pain signaling may occur via diet-induced changes in secretion of mediators by both the microbiota and/or host cells. This review will examine the peripheral influence of diet-microbiota interactions underlying increased visceral sensitivity.
The novel coronavirus (2019; CV-19) is linked to increases in emotional distress and may be particularly problematic for those with pre-existing mental and physical conditions, such as chronic pain ...and posttraumatic stress disorder (PTSD). However, little empirical research has been published on resilience factors in these individuals. The present study aims to examine authenticity as a resilience factor among those with chronic pain and/or PTSD.
Prior to the national response to the pandemic (January 10-24, 2020), participants were screened for pain-related disability (Oswestry Disability Index; ODI) and PTSD symptoms (Posttraumatic Checklist for DSM-5; PCL-5), and on the basis of those responses were categorized into one of four groups: healthy, chronic pain only, PTSD only, or comorbid chronic pain and PTSD. During the CV-19 pandemic (May 5-May 13, 2020), participants responded again to the ODI and PCL-5, in addition to the Wood Authenticity Scale, Brief Pain Inventory, and items related to the CV-19 pandemic.
A total of 110 participants (54.55% women), aged 42.19 (
= 13.16), completed the survey during the pandemic. The comorbid group endorsed higher levels of CV-19 Threat and Impact compared to all other groups. Authenticity moderated this relationship relevant to CV-19 Threat among those in the chronic pain only group, and not in any other group.
The comorbid group endorsed higher levels of CV-19 Threat and Impact compared to all other groups. Importantly, greater authenticity was associated with less CV-19 Threat in the chronic pain only group, and not in any other group. The present study also highlights the importance of engaging authentically for those with chronic pain during the pandemic.
Symptoms of posttraumatic stress disorder (PTSD) are highly prevalent among Veterans with chronic pain. Considerable research has examined the intersection of chronic pain and PTSD symptoms. However, ...it remains unclear whether changes in PTSD may potentially serve a mechanistic role in improving unhelpful pain cognitions for individuals with chronic pain. The present research contributes to the foundational knowledge by addressing this question. Baseline data from a randomized controlled trial targeting pain-related disability for Veterans (
= 103; mean age 43.66;
= 10.17) with musculoskeletal pain and depression and/or PTSD symptoms were used. Cross-sectional mediation analyses showed that PTSD symptoms mediated the relationship between pain severity and pain catastrophizing, and between pain severity and pain acceptance. After controlling for depression, the mediation involving pain catastrophizing remained significant, while the mediation for pain acceptance did not. Although limitations exist, results point to several treatment recommendations, including ensuring that depressive affect, PTSD-specific symptoms, and attention to both body and mind are included in treatment. Results also provide preliminary evidence for examining these associations longitudinally to improve our understanding of this population and corresponding treatment recommendations.
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