Individual and county-level factors associated with use of multiple prescribers and multiple pharmacies to obtain opioid prescriptions in California.

Use of multiple prescribers and pharmacies is a means by which some individuals misuse opioids. Community characteristics may be important determinants of the likelihood of this phenomenon independent of individual-level factors. This was a retrospective cohort study with individual-level data derived from Californias statewide prescription drug monitoring program (PDMP) and county-level socioeconomic status (SES) data derived from the United States Census. Zero-truncated negative binomial (ZTNB) regression was used to model the association of individual factors (age, gender, drug schedule and drug dose type) and county SES factors (ethnicity, adult educational attainment, median household income, and physician availability) with the number of prescribers and the number of pharmacies that an individual used during a single year (2006). The incidence rates of new prescriber use and new pharmacy use for opioid prescriptions declined across increasing age groups. Males had a lower incidence rate of new prescriber use and new pharmacy use than females. The total number of licensed physicians and surgeons in a county was positively, linearly, and independently associated with the number of prescribers and pharmacies that individuals used for prescription opioids. In summary, younger age, female gender, and living in counties with more licensed physicians and surgeons were associated with use of more prescribers and/or more pharmacies for obtaining prescription opioids

A Spline-Based Lack-of-Fit Test for Independent Variable Effect

In regression analysis of count data, independent variables are often modeled by their linear effects under the assumption of log-linearity. In reality, the validity of such an assumption is rarely tested, and its use is at times unjustifiable. A lack-of-fit test is proposed for the adequacy of a postulated functional form of an independent variable within the framework of semiparametric Poisson regression models based on penalized splines. It offers added flexibility in accommodating the potentially non-loglinear effect of the independent variable. A likelihood ratio test is constructed for the adequacy of the postulated parametric form, for example log-linearity, of the independent variable effect. Simulations indicate that the proposed model performs well, and misspecified parametric model has much reduced power. An example is given

Topical clobetasol for the treatment of toxic epidermal necrolysis: study protocol for a randomized controlled trial.

BackgroundToxic epidermal necrolysis (TEN) is a rare systemic allergic drug eruption with high patient mortality. Currently, no established treatments have been shown to be effective for TEN beyond supportive care. Prior studies of systemic corticosteroids have yielded conflicting data, with some showing a possible benefit and others reporting in increased mortality. However, topical steroids have shown promise for treatment of ocular sequelae of TEN, such as scarring and vision loss. We have designed a randomized controlled trial to evaluate topical clobetasol for treatment of the epidermal manifestations of TEN. In addition, we propose genetic studies to characterize the TEN transcriptome and alterations in cutaneous gene expression that might occur following topical steroid treatment.Methods/designThis split-body randomized, double-blind, placebo-controlled Phase IIa proof-of-concept trial will evaluate the safety and efficacy of once-daily topical clobetasol applied to the skin of patients with TEN. This multicenter trial will recruit a total of 15 patients between the ages of 12 and 85 from the University of California Davis Medical Center and Shriners Hospital for Children inpatient burn units. Designated treatment areas on opposite sides of the body will be treated with blinded clobetasol 0.05% ointment or control petrolatum ointment daily for 14 days. On day 3 of therapy, a biopsy will be taken from the treated area for genetic studies. The primary study aims will be to establish the safety of topical clobetasol treatment and determine the time to cessation of skin detachment for the control and clobetasol-treated areas. Secondary endpoints will evaluate efficacy using parameters such as time to 90% re-epithelialization and percentage of affected skin at 0, 3, 6, 9, 12 and 15 days. Genomic DNA and RNA will be obtained from biopsy samples, to characterize the TEN transcriptome and identify changes in gene expression after topical steroid treatment.DiscussionTopical steroids have shown promise for treating ocular complications of TEN, but to date have not been evaluated for cutaneous manifestations of the disease. This trial will investigate clinical and molecular outcomes of topical clobetasol application and hopefully provide insight into the disease pathophysiology.Trial registrationClinicalTrials.gov NCT02319616. https://clinicaltrials.gov/ct2/show/NCT02351037

Clinical Factors Associated with Dense and Wedge-Shaped Nephrograms Detected 24 h After Chemoembolization

This investigation aimed to evaluate patient characteristics and procedural factors associated with abnormal nephrograms encountered on noncontrast computed axial tomography (CAT) obtained 24-h after transarterial chemoembolization (TACE) for primary and metastatic hepatic malignancies. Sixty hepatic chemoembolization procedures were performed in 29 patients who had a median age of 63 years (range 42–79). The male-to-female ratio was 16:13. Noncontrast CAT scans were obtained approximately 24 h after TACE as part of our institutional protocol and were examined for persistent renal nephrograms. These findings were compared with clinical and procedural parameters to determine whether there was any association with these factors or with the occurrence of acute renal failure (ARF). Abnormally persistent CAT nephrograms were observed 24 h after 28 of 60 (46.7%) TACE procedures, of which 14 (23.3%) were persistent, bilaterally dense, global nephrograms, and 14 (23.3%) were small, wedge-shaped, and focal nephrograms. The change in serum creatinine from baseline to 24 h was significantly greater (p = 0.031) in the global nephrogram group. The presence of cirrhosis, Child-Pugh score, procedure time, baseline renal insufficiency, and lower periprocedural mean arterial blood pressure were also statistically significantly associated with the occurrence of bilateral globally dense nephrograms. The procedure time was statistically significantly associated with the occurrence of wedge-like focally persistent nephrograms. Global, persistently dense nephrograms and wedge-shaped focally persistent nephrograms are not infrequently observed after TACE. Persistent global nephrograms can be an important clinical indicator of ARF. The wedge nephrogram may represent focal renal ischemia

Depression, perceived stress and nervios associated with injury in the MICASA Study, a California farm worker population

Introduction: While many studies report on the risks of agricultural injury, few have examined psychosocial factors associated with injury, especially among Latino farm workers. We examined psychological factors, including depression, perceived stress, social support and nervios that may be associated with an increased risk of injury. Methods: MICASA is a population-based study of occupational exposures and health in farm workers. An interviewer-administered questionnaire collected data on 759 Latinos, 18-55 years old, engaged in farm work and residing in Mendota, CA. The questionnaire assessed self-reported psychosocial factors and injury risk. A qualifying injury was defined as one with the need for medical care, going to a medical setting, loss of consciousness, >½ day lost work time or restricted from normal activities. Results: Mean age was 37.9 years. 65.0% of participants were born in Mexico and 27.7% were born in El Salvador. The past-year cumulative incidence of injury was 9.0%. A higher cumulative incidence of past-year injury was observed among participants older than 40 years (55.9% vs. 37.1 %), current smokers (17.7% vs. 10.7%), working in agriculture more than 11 years (65.7% vs. 52.7%), and long-term U.S. residents (more than 21 years) (58.8% vs. 42.6%). After adjusting for age, sex, and current smoking, depression (OR=5.4, 95% CI: 3.1-9.4) and nervios (OR=2.2, 95% CI: 1.3-3.8) were significantly associated with injury. Conclusions: The findings may be useful for guiding prevention and management of injury. Further cohort research to confirm the temporality of the association between psychosocial variables and injury is needed.Introduction : De nombreuses études ont examiné les risques de blessures en milieu agricole mais peu se sont intéressées aux facteurs psychosociaux associés à ces blessures, en particulier parmi les ouvriers agricoles latinos. Nous avons étudié les facteurs psychologiques, notamment la dépression, le stress ressenti, le soutien social et l'état de nervosité qui peuvent être liés à un risque accru de blessures. Méthodes : L'étude MICASA est une étude de population qui porte sur les expositions professionnelles et la santé des ouvriers agricoles. Un questionnaire rempli par un enquêteur a permis de recueillir des données sur 759 Latinos, de 18 à 55 ans, ouvriers agricoles et résidant à Mendota, en Californie. Ce questionnaire a évalué les facteurs psychosociaux auto-déclarés et le risque de blessure. Une blessure admissible a été définie comme une blessure impliquant des soins médicaux, une visite dans un établissement médical, une perte de connaissance, >½ journée d'arrêt de travail ou d'activités limitées. Résultats : L'âge moyen était de 37,9 ans. 65,0 % des participants étaient nés au Mexique et 27,7 % au Salvador. L'incidence cumulée de blessures l'année précédente était de 9,0 %. Une plus grande incidence cumulée de blessures l'année précédente a été observée parmi les participants âgés de plus de 40 ans (55,9 % vs. 37,1 %), les fumeurs (17,7 % vs. 10,7 %), ceux travaillant dans l'agriculture depuis plus de 11 ans (65,7 % vs. 52,7 %), et les résidents américains de longue durée (plus de 21 ans) (58,8 % vs. 42,6 %). Après ajustement en fonction du sexe et du tabagisme, la dépression (OR=5,4, IC à 95 % : 3,1-9,4) et l'état de nervosité (OR=2,2, IC à 95 % : 1,3-3,8) ont été associés de manière significative à des blessures.  Conclusions : Les résultats peuvent être utiles pour orienter la prévention et la prise en charge des blessures. D'autres études de cohortes sont nécessaires pour confirmer la temporalité de l'association entre les variables psychosociales et les blessures.Introducción: Aunque se han realizado numerosos estudios sobre los riesgos de lesiones en la agricultura, pocos son los que han examinado los factores psicosociales asociados a dichas lesiones, especialmente entre los trabajadores agrícolas latinos. Hemos estudiado los factores psicosociales, tales como la depresión, el estrés percibido, el apoyo social y los nervios, que pueden asociarse a un mayor riesgo de lesiones. Métodos: MICASA es un estudio de población sobre exposiciones y salud occupacionales en trabajadores agrícolas. Un cuestionario realizado por entrevistador recogió datos de 759 latinos, de entre 18 y 55 años de edad, que realizaban labores agrícolas y con residencia en Mendota (California). El cuestionario evaluaba los factores sociales y el riesgo de lesiones declarados por los encuestados. Las lesiones por las que calificaban para el estudio eran aquellas que requerían asistencia médica o la visita a un centro médico, que implicaban pérdida de conciencia o pérdida de más de medio día de trabajo o que restringían la realización de actividades normales. Resultados: La edad media era de 37.9 años. El 65,0% de los participantes eran originarios de México y el 27.7% de El Salvador. La incidencia acumulada de lesiones del año pasado fue del 9.0%. Se observó una mayor incidencia acumulada de lesiones el año pasado entre participantes de más de 40 años (55.9% contra 37.1 %), fumadores activos (17.7% contra 10.7%), que llevan trabajando en la agricultura más de 11 años (65.7% contra 52.7%) y los residentes en Estados Unidos por un  largo plazo (más de 21 años) (58.8% contra 42.6%). Tras ajustar los resultados por edad, sexo, condición de fumador, la depresión (OR=5,4; 95% IC: 3,1-9,4) y los nervios (OR=2,2, 95% IC: 1.3-3.8) se asociaron de forma importante a las lesiones. Conclusiones: Las conclusiones extraídas pueden ser de utilidad para guiar la prevención y manejo de lesiones. Es necesario realizar otros estudios de cohortes para confirmar la temporalidad de la asociación entre las variables psicosociales y las lesiones

The prevalence and awareness of sleep apnea in patients suffering chronic pain: an assessment using the STOP-Bang sleep apnea questionnaire.

Purpose: Some patient subsets are at higher risk of sleep apnea, including patients with chronic pain. However, it is unclear whether patients and their caregivers are aware of the possibly increased risk of sleep apnea in this population. Chronic pain is often treated with opioids which may decrease both the central respiratory drive and the patency of the upper airway, potentially contributing to this sleep disorder. Using a self-reporting questionnaire approach in the chronic pain population, this study surveyed patient and caregiver awareness surrounding the risk of sleep apnea. In addition, we looked at the influence of opioid therapy on the prevalence of sleep apnea. Participants and methods: Consecutive patients presenting to a pain clinic were invited to participate anonymously in a survey that included the STOP-Bang sleep apnea questionnaire, which assesses patients\u27 knowledge, testing, diagnosis, or treatment of sleep apnea and whether their caregivers had discussed with them their increased risk of sleep apnea and opioid use. Results: Among 305 participating patients, 58.2% (n=173) screened positive for sleep apnea. Among the 202 patients on opioid therapy, 59.2% (116/202) were STOP-Bang positive (score ≥3). However, only 37.5% (n=72/173) of these patients had discussed their risk of sleep apnea with a caregiver and only 30.7% (n=59) underwent testing. Against expectation, opioids did not increase the prevalence of sleep apnea in our study population. Conclusion: Chronic pain patients had a high risk of sleep apnea, regardless of opioid prescription. Most patients were unaware of their increased risk and denied undergoing the necessary testing. Greater attention to screening, testing, and education for sleep apnea needs to be paid in chronic pain patients, especially given the potentially dangerous ramifications of opioid-induced sleep apnea