Abstract Background The prevalence of chronic pain conditions is growing. Low back pain was the primary cause of disability worldwide out of 156 conditions assessed between 1990 and 2016, according ...to the Global Burden of Disease Study. Conventional medical approaches have failed to identify effective and long-lasting approaches for the management of chronic pain, and often fail to consider the multiple domains that influence overall health and can contribute to the pain experience. Leading international organizations that focus on pain research have stated the importance of considering these other domains within holistic and multidisciplinary frameworks for treating pain. While the research behind the theoretical link between these domains and chronic pain outcomes has expanded greatly over the last decade, there have been few practical and feasible methods to implement this type of care in normal clinical practice. Methods The purpose of this manuscript is to describe an implementation protocol that is being used to deliver a complex holistic health intervention at multiple sites within a large government health system, as part of a larger multisite trial for patients with chronic low back pain. The Move to Health program developed by the US Army Medical Command was tailored for specific application to patients with low back pain and begins by providing an empirical link between eight different health domains (that include physical, emotional, social, and psychological constructs) and chronic low back pain. Through a six-step process, a health coach leverages motivational interviewing and information from a personal health inventory to guide the patient through a series of conversations about behavioral lifestyle choices. The patient chooses which domains they want to prioritize, and the health coach helps implement the plan with the use of SMART (Specific, Measurable, Attainable, Realistic, Time-bound) goals and a series of resources for every domain, triaged from self-management to specialist referral. Discussion Complex interventions described in clinical trials are often challenging to implement because they lack sufficient details. Implementation protocols can improve the ability to properly deliver trial interventions into regular clinical practice with increased fidelity. Trial registration Implementation of this intervention protocol was developed for a clinical trial that was registered a priori (clinicaltrials.gov #NCT04172038).
Parallel-arm randomized controlled trial.
To assess the effectiveness of an enhanced video education session highlighting risks of opioid utilization on longterm opioid utilization after spine ...surgery.
Long-term opioid use occurs in more than half of patients undergoing spine surgery and strategies to reduce this use are needed.
Patients undergoing spine surgery at Brooke Army Medical Center between July 2015 and February 2017 were recruited at their preoperative appointment, receiving the singlesession interactive video education or control at that same appointment. Opioid utilization was tracked for the full year after surgery from the Pharmacy Data Transaction Service of the Military Health System Data Repository. Self-reported pain also collected weekly for 1 and at 6months.
A total of 120 participants (40 women, 33.3%) with a mean age of 45.9 ± 10.6 years were randomized 1:1 to the enhanced education and usual care control (60 per group). In the year following surgery the cohort had a mean 5.1 (standard deviation SD 5.9) unique prescription fills, mean total days' supply was 88.3 (SD 134.9), and mean cumulative morphine milligrams equivalents per participant was 4193.0 (SD 12,187.9) within the year after surgery, with no significant differences in any opioid use measures between groups. Twelve individuals in the standard care group and 13 in the enhanced education group were classified with having long-term opioid utilization.
The video education session did not influence opioid use after spine surgery compared to the usual care control. There was no significant difference in individuals classified as long-term opioid users after surgery based on the intervention group. Prior opioid use was a strong predictor of future opioid use in this cohort. Strategies to improve education engagement, understanding, and decision- making continue to be of high importance for mitigating risk of long-term opioid use after spine surgery.Level of Evidence: 1.
X-linked sideroblastic anaemia (XLSA) is commonly due to mutations in the ALAS2 gene and predominantly affects hemizygous males. Heterozygous female carriers of the ALAS2 gene mutation are often ...asymptomatic or only mildly anaemic. XLSA is usually characterized by microcytic erythrocytes (reduced mean corpuscular volume (MCV)) and hypochromia, along with increased red cell distribution width. However, in females with XLSA the characteristic laboratory findings can be dimorphic and present with macrocytic (elevated MCV) in addition to microcytic red cells.
We report a case of fetal anaemia, presenting in the early third trimester of pregnancy, in a female fetus. Ultrasound findings at 29 weeks were of cardiomegaly, prominent umbilical veins, a small rim of ascites, and mean cerebral artery peak systolic velocity (PSV) value above 1.5 Multiples of the Median (MoM). She underwent non-invasive prenatal testing that determined the rhesus genotype of the fetus to be rhesus B negative. No red blood cell antibodies were reported. Other investigations to determine the underlying cause of fetal anaemia included microarray comparative genomic hybridization, serology to exclude congenital infection and a peripheral blood film and fetal bilirubin to detect haemolysis. The maternal grandmother had a history of sideroblastic anaemia diagnosed at the age of 17 years. The mother had mild macrocytic anaemia with haemoglobin of 10.4 g/dl and MCV of 104 fl. The fetal anaemia was successfully treated with two in utero transfusions (IUTs), and delivery occurred via caesarean section at 37 weeks of gestation. The red cell gene sequencing in both the mother and fetus were heterozygous for an ALAS2 mutation causing in utero manifestations of XLSA. The haemoglobin on discharge to the local hospital at five days of age was 19.1 g/dl. Subsequently, the infant became anaemic, requiring regular 3-4 monthly blood transfusions and demonstrating overall normal development. Her anaemia was unresponsive to pyridoxine.
This is one of four cases reporting multiple female members presenting with discordant clinical features of XLSA from being entirely asymptomatic to hydropic in utero. Our report is novel in that there are no previous cases in the literature of anaemia in a female fetus heterozygous for ALAS2 mutation.
Abstract
Background
Adherence to guidelines for back pain continues to be a challenge, prompting strategies focused on improving education around biopsychosocial frameworks.
Objective
Assess the ...influence of an interactive educational mobile app for patients on initial care decisions made for low back pain by the primary care provider. The secondary aim was to compare changes in self-reported pain and function between groups.
Methods
This was a randomized controlled trial involving patients consulting for an initial episode of low back pain. The intervention was a mobile video-based education session (Truth About Low Back Pain) compared to usual care. The app focused on addressing maladaptive beliefs typically associated with higher risk of receiving low-value care options. The primary outcome was initial medical utilization decisions made by primary care practitioners (x-rays, MRIs, opioid prescriptions, injections, procedures) and secondary outcomes included PROMIS pain interference and physical function subscales at 1 and 6 months, and total medical costs.
Results
Of 208 participants (71.2% male; mean age 35.4 years), rates of opioid prescriptions, advanced imaging, analgesic patches, spine injections, and physical therapy use were lower in the education group, but the differences were not significant. Total back-related medical costs for 1 year (mean diff = $132;
P
= 0.63) and none of the 6-month PROMIS subscales were significantly different between groups. Results were no different in opioid-naïve subjects. Instead, prior opioid use and high-risk of poor prognosis on the STarT Back Screening Tool predicted 1-year back pain-related costs and healthcare utilization, regardless of intervention.
Conclusion
Factors that influence medical treatment decisions and guideline-concordant care are complex. This particular patient education approach directed at patients did not appear to influence healthcare decisions made by primary care providers. Future studies should focus on high-risk populations and/or the impact of including the medical provider as an active part of the educational process.
Trial Registration
clinicaltrials.gov
NCT02777983
.
Chronic non-cancer pain (CNCP) is significant global health issue, accounting for a substantial increase in prescription analgesics worldwide, in recent decades. This clinical burden is evident in ...the UK prison population, where the prevalence of CNCP has never previously been determined. This study, conducted in June/July 2013, used prescribing data and a systematic review of clinical records from two UK prison establishments to derive a figure for point-prevalence of CNCP. Results showed that 20% of the total aggregated prisoner rolls (N = 1944) described CNCP and had been in receipt of treatment with daily analgesia, for a period of at least 3 months prior to observation date. This prevalence of CNCP was related to increasing age group (Spearman’s rank correlation 0.94). Of those on continuous analgesic therapy (CAT), 44% were taking continuous opioid therapy (COT) of any sort. Prisoners with a diagnosis of opioid-type drug dependence (OTDD) were more than twice as likely to complain of CNCP and be on continuous medication for it (odds ratio 2.3). The issues relating to CNCP in prisons are discussed. Further research is recommended, identifying factors influencing CNCP prevalence in prisons, and enabling comparisons to CNCP prevalence in the UK general population.
Abstract
Introduction
With the rapid rise in arthroscopy rates for the management of Femoroacetabular Impingement (FAI) Syndrome, it is important to understand current surgical rates and the impact ...of these surgeries within the Military Health System (MHS). The purpose of this study was to provide an epidemiological descriptive summary of hip arthroscopy for FAI Syndrome in the MHS and describe perioperative healthcare utilization variables.
Methods
Eligible beneficiaries ages 18–50, undergoing hip arthroscopy with 2-year follow-up after surgery were included. Healthcare utilization data were abstracted from the MHS Data Repository (MDR) from June 2003 to July 2015, and included all visits, costs, procedures, and prescriptions taking place in both military and civilian hospitals worldwide.
Results
1870 patients were included (mean age 32.2 years; 55.5% male). 51.7% of the procedures took place in military versus 48.3% in civilian hospitals. Mean hip-related healthcare costs in the 2-year following surgery were $15,434 per patient. Patients had a median of 3 opioid prescriptions and 72% had a comorbidity present after surgery. Generally, rates of surgery grew annually from 66 cases in 2004 to 422 cases in 2013. Overall complication rates were comparable to other published reports. Procedures in both military and civilian hospitals had the same rates of femoroplasty and labral repairs, however acetabuloplasty procedures occurred at a higher rate in military (18.9%) vs civilian (14.7%) hospitals. Only 58.8% of patients had physical therapy in the year prior to surgery, while 82.7% had it after surgery. Additionally, 50% of patients had received opioid prescriptions in the 1 year prior to surgery, while 38.9% had 3 or greater opioid prescriptions beyond the initial perioperative fill within the 2-year follow-up.
Conclusion
Rates of arthroscopy have grown in the MHS over the last decade. Complication rates are similar to those reported in other populations and settings. Utilization of physical therapy was much more likely after surgery than prior to it. Opioid use was high prior to surgery and many individuals continued to receive opioid prescriptions beyond the initial perioperative period.
After elective orthopaedic surgery, many individuals go on to become long-term opioid users. Mitigating this risk has become a priority for surgeons, other members of the medical care team, and ...healthcare systems. The purpose of this study was to compare opioid utilization after lower extremity orthopaedic surgery between patients who received an interactive video education session highlighting the risks of opioid use and those who did not.
Patients undergoing elective surgery of the lower extremity in the orthopaedic clinic at the Brooke Army Medical Center between July 2015 and February 2017 were recruited at their preoperative appointment and randomized in a 1:1 ratio to receive a one-time interactive opioid education session or usual care education. Unique days' supply of opioids and unique prescriptions were compared using a generalized linear model. Individuals were also grouped by whether they had become long-term opioid users after surgery, and frequencies within each intervention group were compared.
There were 120 patients, 60 randomized to each group and followed for 1 year. There were no significant differences between opioid days' supply (mean diff = 8.33, 95% confidence interval -4.21 to 20.87) and unique prescriptions after surgery (mean diff = 0.45, 95% confidence interval -0.25 to 1.15). Most participants did not have any opioids past the initial 30 days after surgery, regardless of intervention (n = 77), and only three became long-term opioid users (one in usual care and two in interactive education). Sixteen in usual education and 18 in enhanced education filled at least one prescription in 6 months or later after the surgical procedure.
Opioid use beyond 30 days of surgery was no different for participants who received enhanced education compared with usual education. Few became long-term opioid users after surgery (2.5%), although 28.3% were still filling opioid prescriptions 6 months after surgery.
The genetic diagnosis of inherited anaemias is an important aspect of the diagnostic pathway for patients with haematological disorders, allowing discrimination between conditions of overlapping ...phenotypes therefore enabling more effective clinical treatment. Next Generation sequencing platforms are now in widespread use in diagnostic settings and are facilitating more rapid, accurate and cost-effective molecular diagnosis. The Red Cell Gene Panel developed by the Viapath Molecular Pathology laboratory based at King's College Hospital, London has harnessed this technology with the aim of identifying genetic diagnoses of rare inherited causes of anaemia. Although originally setup to diagnose inherited red cell disorders, clinical demand has led to the inclusion of inherited bone marrow failure syndromes and other related conditions such that the panel now consists of 194 genes, divided into 16 subpanels (see table 1).
Here we present the data from the first 1000 diagnostic cases reported under the following referral groups: 462 cases of unexplained anaemia (including haemolytic anaemia, sideroblastic anaemia, congenital dyserythropoietic anaemia, Diamond-Blackfan Anaemia), 232 cases of inherited bone marrow failure syndromes (including thrombocytopenia and neutropenia), 163 cases of congenital erythrocytosis and 143 other cases (including but not limited to iron regulation, haemophagocytic lymphohistiocytosis (HLH) and Criggler-Najjar ). Of these 1000 cases, we have achieved an overall diagnostic yield of approximately 25%. A diagnosed case is defined here as one in which a clear pathogenic or likely pathogenic variant that explains the phenotype has been detected. The unexplained anaemia cases have achieved the highest percentage of cases diagnosed with 47% diagnostic yield and data will be presented outlining the gene-by-gene breakdown of diagnoses made.
Our bespoke bioinformatics pipeline has also allowed the detection of novel disease-causing structural variants in 20 cases, contributing 2% of our diagnostic yield. These are detected using three different methods; read-depth analysis, split-read mapping and discordant insert-size analysis. All reported structural variants have been confirmed with a second method, either breakpoint mapping or dosage-sensitive PCR.
A significant proportion of cases (28%) have been reported with variants of uncertain clinical significance, highlighting the need for family studies and functional characterisation to be able to accurately ascertain the significance of these variants. Future developments of the service include functional characterisation of membrane disorders using next generation ektacytometry and preliminary data from this work will be presented here.
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Kulasekararaj:Alexion Pharmaceuticals, Inc.: Consultancy, Honoraria, Other: Travel Support . Pagliuca:Gentium: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Jazz Pharmaceuticals: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau.
Abstract
Background
Physical therapy services delivered remotely are becoming more common. The purpose was to summarize the acceptability and patient-centeredness of remotely delivered physical ...therapy.
Methods
This was a survey study. Patients and clinicians from physical therapy clinics in the US Military Health System were asked to provide feedback at the conclusion of each remote visit. Platform, reason for care, components of physical therapy delivered and received, satisfaction, and perception of patient-centeredness were collected. Results were summarized as proportions and frequencies.
Results
Feedback was provided by physical therapists for 250 visits and from patients for 61 visits. Most visits were completed using audio only (
n
= 172; 68.8%) while the rest integrated video capability (
n
= 78; 31.2%). Overall patients perceived their care was patient-centered either completely or very much. Over 90% of visits were perceived by physical therapists as being highly patient centered. For 53.2% of visits, patients thought that same visit would have been even more impactful in person and for 52.4% of visits, physical therapists thought the visit would have been more impactful in person.
Conclusion
Even though remotely provided physical therapy care was rated by patients to be patient-centered, approximately half of the patients responding felt the same physical therapy visit would have been more impactful in person. Similarly, physical therapists felt that their intervention would have been more impactful in person for approximately half of all visits. Physical therapy care delivered remotely was patient-centered and an acceptable alternative to in-person care for both patients and physical therapists.
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