Dysmenorrhea Symptom-Based Phenotypes: A Replication and Extension Study

BACKGROUND: Dysmenorrhea is a prevalent pain condition among women and a risk factor for other chronic pain conditions. Individuals vary in dysmenorrhea pain severity, the number of painful sites, and co-occurring gastrointestinal symptoms. Three dysmenorrhea symptom-based phenotypes were previously identified using latent class analysis; however, there is a need to validate these in an independent sample, so they can be used in mechanistic and interventional research. There also is a need to further characterize dysmenorrhea symptom-based phenotypes in terms of demographic, clinical, and psychobehavioral characteristics so they can be used to inform precision dysmenorrhea treatment. OBJECTIVES: The study objectives were to: (a) determine whether the same dysmenorrhea symptom-based phenotypes would be found in a new sample; (b) determine whether including demographic, clinical, and psychobehavioral covariates in latent class analyses would change individuals’ phenotype memberships; and (c) investigate relationships between dysmenorrhea symptom-based phenotypes and demographic, clinical, and psychobehavioral characteristics. METHODS: This cross-sectional survey study included 678 women (aged 14 to 42 years) with dysmenorrhea. Participants reported dysmenorrhea symptom severity, demographic, clinical (comorbid chronic pain and gynecological conditions), and psychobehavioral characteristics (perceived stress, anxiety, depression, sleep disturbance, and pain catastrophizing). We used latent class analysis to identify symptom-based phenotypes. We compared analyses with and without covariates (i.e., demographic, clinical, and psychobehavioral characteristics) to determine if individuals’ phenotype memberships changed. We then examined associations between phenotypes and demographic, clinical, and psychobehavioral characteristics. RESULTS: We reproduced three dysmenorrhea symptom-based phenotypes: the “mild localized pain” phenotype (characterized by mild abdominal cramps), the “severe localized pain” phenotype (characterized by severe abdominal cramps), and the “multiple severe symptoms” phenotype (characterized by severe pain at multiple locations and gastrointestinal symptoms). Analyses with and without covariates had little effect on individuals’ phenotype membership. Race, comorbid chronic pain condition, endometriosis, and pain catastrophizing were significantly associated with the dysmenorrhea phenotypes. DISCUSSION: Findings provide a foundation to further study mechanisms of dysmenorrhea symptom heterogeneity and develop dysmenorrhea precision treatments. The three dysmenorrhea symptom-based phenotypes were validated in a second sample. Demographic, clinical, and psychobehavioral factors were associated with dysmenorrhea symptom-based phenotypes

Using HCAHPS data to model correlates of medication understanding at hospital discharge

Background: Hospitals are challenged to improve hospital transitions to home and are held accountable through public reporting. Design: This cross-sectional study used patients’ self-reported experience data from the publicly reported Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to describe correlates of medication understanding at hospital discharge, using data collected from adult patients discharged from one Midwestern community hospital (N=154). Results: The final logistic regression model included four correlates of medication understanding: 1) nurse always communicates well, 2) physician always communicates well, 3) new prescriptions during hospital stay, and 4) very good or better mental health, and these classified 72.6% of the cases. Significant correlates of the patient strongly agreeing that they understood discharge medications were the “nurse always communicates well” (odds ratio =3.10, 95% confidence interval: 1.25, 7.66) and “very good or better self-perceived mental health” (odds ratio =2.17, 95% confidence interval: 1.02, 4.64). Conclusion: HCAHPS data can be used to model correlates of medication understanding, which are then useful for evaluating intervention effects following quality improvement

Moregrasp: Restoration of Upper Limb Function in Individuals with High Spinal Cord Injury by Multimodal Neuroprostheses for Interaction in Daily Activities

The aim of the MoreGrasp project is to develop a noninvasive, multimodal user interface including a brain-computer interface (BCI) for intuitive control of a grasp neuroprosthesis to support individuals with high spinal cord injury (SCI) in everyday activities. We describe the current state of the project, including the EEG system, preliminary results of natural movements decoding in people with SCI, the new electrode concept for the grasp neuroprosthesis, the shared control architecture behind the system and the implementation of a user-centered design

Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke

Importance: Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes. Objective: To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke. Design, Setting, and Participants: This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019. Main Outcomes and Measures: Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation. Results: Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0%) were men, 5929 (73.4%) were white, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within 1 year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3%; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2% lower odds of 1-year mortality (aOR, 0.69; 95% CI, 0.55-0.87) but was not independently associated with stroke risk. Conclusions and Relevance: Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible

Care Trajectories of Veterans in the Twelve Months following Hospitalization for Acute Ischemic Stroke

Background—Recovery after a stroke varies greatly between individuals and is reflected by wide variation in the use of institutional and home care services. This study sought to classify veterans according to their care trajectories in the 12 months after hospitalization for ischemic stroke. Methods and Results—The sample consisted of 3811 veterans hospitalized for ischemic stroke in Veterans Health Administration facilities in 2007. Three outcomes—nursing home care, home care, and mortality—were modeled jointly >12 months using latent class growth analysis. Data on Veterans’ care use and cost came from the Veterans Administration and Medicare. Covariates included stroke severity (National Institutes of Health Stroke Scale), functional status (functional independence measure score), age, marital status, chronic conditions, and prestroke ambulation. Five care trajectories were identified: 49% of Veterans had Rapid Recovery with little or no use of care; 15% had a Steady Recovery with initially high nursing home or home care that tapered off; 9% had Long-Term Home Care; 13% had Long-Term Nursing Home Care; and 14% had an Unstable trajectory with multiple transitions between long-term and acute care settings. Care use was greatest for individuals with more severe strokes, lower functioning at hospital discharge, and older age. Average annual costs were highest for individuals with the Long-Term Nursing Home trajectory ($63 082), closely followed by individuals with the Unstable trajectory ($58 720). Individual with the Rapid Recovery trajectory had the lowest costs ($9271). Conclusions—Care trajectories after stroke were associated with stroke severity and functional dependency and they had a dramatic impact on subsequent costs

Time From First Intercourse to First Sexually Transmitted Infection Diagnosis Among Adolescent Women

Objective To determine the time between first intercourse and first sexually transmitted infection (STI) with Chlamydia trachomatis, Neisseria gonorrhoeae, or Trichomonas vaginalis and time between repeated infections. Design Observational study. Setting Three adolescent medicine clinics. Participants A cohort of 386 urban young women aged 14 to 17 years at enrollment. Main Outcome Measures Age at first intercourse; organism-specific interval between first intercourse and first STI diagnosis; interval between repeated infections; and age at first STI test prior to study participation. Results Participants had first intercourse at a young age (first, second, and third quartiles were 13, 14, and 15 years of age, respectively). By age 15 years, 25% of the women acquired their first STI, most often C trachomatis. Median interval between first intercourse and first STI diagnosis was 2 years. Within 1 year of first intercourse, 25% had their first C trachomatis infection. Repeated infections were common; within 3.6, 6, and 4.8 months, 25% of the women with prior C trachomatis, N gonorrhoeae, and T vaginalis infection were reinfected with the respective organisms. Considerable delay in STI testing was found for those who began sex at a younger age. The median interval between first sex and first test were 4.9, 3.5, 2.1, 1.8, and 1.2 years for those who had first sex at ages 10, 11, 12, 13, and 14 years, respectively. Conclusions Timely screening and treatment are important for prevention of STI sequelae. For urban adolescent women, STI screening (especially for C trachomatis) should begin within a year after first intercourse and infected individuals should be retested every 3 to 4 months

Does Inclusion of Stroke Severity in a 30-day Mortality Model Change Standardized Mortality Rates at VA Hospitals?

Background—The Centers for Medicare and Medicaid Services is considering developing a 30-day ischemic stroke hospital-level mortality model using administrative data. We examined whether inclusion of the National Institutes of Health Stroke Scale (NIHSS), a measure of stroke severity not included in administrative data, would alter 30-day mortality rates in the Veterans Health Administration. Methods and Results—A total of 2562 veterans admitted with ischemic stroke to 64 Veterans Health Administration Hospitals in the fiscal year 2007 were included. First, we examined the distribution of unadjusted mortality rates across the Veterans Health Administration. Second, we estimated 30-day all-cause, risk standardized mortality rates (RSMRs) for each hospital by adjusting for age, sex, and comorbid conditions using hierarchical models with and without the inclusion of the NIHSS. Finally, we examined whether adjustment for the NIHSS significantly changed RSMRs for each hospital compared with other hospitals. The median unadjusted mortality rate was 3.6%. The RSMR interquartile range without the NIHSS ranged from 5.1% to 5.6%. Adjustment with the NIHSS did not change the RSMR interquartile range (5.1%–5.6%). Among veterans ≥65 years, the RSMR interquartile range without the NIHSS ranged from 9.2% to 10.3%. With adjustment for the NIHSS, the RSMR interquartile range changed from 9.4% to 10.0%. The plot of 30-day RSMRs estimated with and without the inclusion of the NIHSS in the model demonstrated overlapping 95% confidence intervals across all hospitals, with no hospital significantly below or above the mean-unadjusted 30-day mortality rate. The 30-day mortality measure did not discriminate well among hospitals. Conclusions—The impact of the NIHSS on RSMRs was limited. The small number of stroke admissions and the narrow range of 30-day stroke mortality rates at the facility level in the Veterans Health Administration cast doubt on the value of using 30-day RSMRs as a means of identifying outlier hospitals based on their stroke care quality

Natural formation of chloro- and bromoacetone in salt lakes of Western Australia

Western Australia is a semi-/arid region known for saline lakes with a wide range of geochemical parameters (pH 2.5-7.1, Cl- 10-200 g L-1. This study reports on the haloacetones chloro- and bromoacetone in air over 6 salt lake shorelines. Significant emissions of chloroacetone (up to 0.2 µmol m-2 h-1) and bromoacetone (up to 1. 5 µmol m-2 h-1) were detected, and a photochemical box model was employed to evaluate the contribution of their atmospheric formation from the olefinic hydrocarbons propene and methacrolein in the gas phase. The measured concentrations could not explain the photochemical halogenation reaction, indicating a strong hitherto unknown source of haloacetones. Aqueous-phase reactions of haloacetones, investigated in the laboratory using humic acid in concentrated salt solutions, were identified as alternative formation pathway by liquid-phase reactions, acid catalyzed enolization of ketones, and subsequent halogenation. In order to verify this mechanism, we made measurements of the Henry's law constants, rate constants for hydrolysis and nucleophilic exchange with chloride, UV-spectra and quantum yields for the photolysis of bromoacetone and 1,1-dibromoacetone in the aqueous phase. We suggest that heterogeneous processes induced by humic substances in the quasi-liquid layer of the salt crust, particle surfaces and the lake water are the predominating pathways for the formation of the observed haloacetones

Perceived Ineffectiveness of Pharmacological Treatments for Dysmenorrhea

Background: Dysmenorrhea affects most reproductive-aged women. Common dysmenorrhea treatments vary in their effectiveness across individuals. Little is known about factors associated with perceived treatment ineffectiveness. The objectives of this study were to describe the perceived ineffectiveness of common pharmacological treatments for dysmenorrhea and investigate factors associated with perceived treatment ineffectiveness. Materials and Methods: In this cross-sectional study, 678 women with dysmenorrhea (aged 14-42) provided data on perceived treatment ineffectiveness, dysmenorrhea symptom-based phenotypes, demographics, clinical factors, and psychobehavioral characteristics. We used Fisher's exact tests to compare treatment ineffectiveness across three symptom-based phenotypes. We used logistic regressions to explore associations of phenotype, demographic, clinical, and psychobehavioral correlates of perceived treatment ineffectiveness. Results: Percentages perceiving treatments as ineffective were 29.3%-35.6% nonsteroidal anti-inflammatory drugs, 49.9% acetaminophen, and 39.3% combined oral contraceptive pills (OCPs). Factors associated with perceived ineffectiveness varied across treatments and included symptom-based phenotypes, clinical, and psychobehavioral factors. For ibuprofen and acetaminophen, women with severe (vs. mild) pain phenotype and higher number of chronic pain conditions were more likely to perceive the treatments as ineffective. For OCPs, women with severe pain (vs. mild) phenotype, comorbid gynecological condition, less anxiety, and worse depressive symptoms were more likely to perceive the treatment as ineffective. Conclusion: A significant percentage of women reported ineffectiveness of dysmenorrhea treatments. Phenotypes, clinical, and psychobehavioral factors were associated with treatment ineffectiveness. Future research should test if symptom-based phenotypes are associated with treatment effectiveness in clinical trials and investigate other factors that affect dysmenorrhea treatment effectiveness, so treatments can be tailored to individuals