Does Screening for Pain Correspond to High Quality Care for Veterans?

Routine numeric screening for pain is widely recommended, but its association with overall quality of pain care is unclear. To assess adherence to measures of pain management quality and identify associated patient and provider factors. A cross-sectional visit-based study. One hundred and forty adult VA outpatient primary care clinic patients reporting a numeric rating scale (NRS) of moderate to severe pain (four or more on a zero to ten scale). Seventy-seven providers completed a baseline survey regarding general pain management attitudes and a post-visit survey regarding management of 112 participating patients. We used chart review to determine adherence to four validated process quality indicators (QIs) including noting pain presence, pain character, and pain control, and intensifying pharmacological intervention. The average NRS was 6.7. Seventy-three percent of charts noted the presence of pain, 13.9% the character, 23.6% the degree of control, and 15.3% increased pain medication prescription. Charts were more likely to include documentation of pain presence if providers agreed that “patients want me to ask about pain” and “pain can have negative consequences on patient’s functioning”. Charts were more likely to document character of pain if providers agreed that “patients are able to rate their pain”. Patients with musculoskeletal pain were less likely to have chart documentation of character of pain. Despite routine pain screening in VA, providers seldom documented elements considered important to evaluation and treatment of pain. Improving pain care may require attention to all aspects of pain management, not just screening

Selective Serotonin Reuptake Inhibitor Use Is Associated with Right Ventricular Structure and Function: The MESA-Right Ventricle Study

PURPOSE:Serotonin and the serotonin transporter have been implicated in the development of pulmonary hypertension (PH). Selective serotonin reuptake inhibitors (SSRIs) may have a role in PH treatment, but the effects of SSRI use on right ventricular (RV) structure and function are unknown. We hypothesized that SSRI use would be associated with RV morphology in a large cohort without cardiovascular disease (N = 4114). METHODS:SSRI use was determined by medication inventory during the Multi-Ethnic Study of Atherosclerosis baseline examination. RV measures were assessed via cardiac magnetic resonance imaging. The cross-sectional relationship between SSRI use and each RV measure was assessed using multivariable linear regression; analyses for RV mass and end-diastolic volume (RVEDV) were stratified by sex. RESULTS:After adjustment for multiple covariates including depression and left ventricular measures, SSRI use was associated with larger RV stroke volume (RVSV) (2.75 mL, 95% confidence interval [CI] 0.48-5.02 mL, p = 0.02). Among men only, SSRI use was associated with greater RV mass (1.08 g, 95% CI 0.19-1.97 g, p = 0.02) and larger RVEDV (7.71 mL, 95% 3.02-12.40 mL, p = 0.001). SSRI use may have been associated with larger RVEDV among women and larger RV end-systolic volume in both sexes. CONCLUSIONS:SSRI use was associated with higher RVSV in cardiovascular disease-free individuals and, among men, greater RV mass and larger RVEDV. The effects of SSRI use in patients with (or at risk for) RV dysfunction and the role of sex in modifying this relationship warrant further study

Cigarette smoking, nicotine dependence and anxiety disorders : a systematic review of population-based, epidemiological studies

Background Multiple studies have demonstrated that rates of smoking and nicotine dependence are increased in individuals with anxiety disorders. However, significant variability exists in the epidemiological literature exploring this relationship, including study design (cross-sectional versus prospective), the population assessed (random sample versus clinical population) and diagnostic instrument utilized.Methods We undertook a systematic review of population-based observational studies that utilized recognized structured clinical diagnostic criteria (Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD)) for anxiety disorder diagnosis to investigate the relationship between cigarette smoking, nicotine dependence and anxiety disorders.Results In total, 47 studies met the predefined inclusion criteria, with 12 studies providing prospective information and 5 studies providing quasiprospective information. The available evidence suggests that some baseline anxiety disorders are a risk factor for initiation of smoking and nicotine dependence, although the evidence is heterogeneous and many studies did not control for the effect of comorbid substance use disorders. The identified evidence however appeared to more consistently support cigarette smoking and nicotine dependence as being a risk factor for development of some anxiety disorders (for example, panic disorder, generalized anxiety disorder), although these findings were not replicated in all studies. A number of inconsistencies in the literature were identified.Conclusions Although many studies have demonstrated increased rates of smoking and nicotine dependence in individuals with anxiety disorders, there is a limited and heterogeneous literature that has prospectively examined this relationship in population studies using validated diagnostic criteria. The most consistent evidence supports smoking and nicotine dependence as increasing the risk of panic disorder and generalized anxiety disorder. The literature assessing anxiety disorders increasing smoking and nicotine dependence is inconsistent. Potential issues with the current literature are discussed and directions for future research are suggested

A Turbo Environment for Producing Algorithm Animations

We describe GEF, a fast turnaround environment for developing algorithms animations. GEF is an interpreted programming language with operations for defining graphic objects and animations. Introduction Animating algorithms is hard. Creating an animation that clearly communicates the essence of an algorithm is an art. The animation designer must take the internal states and actions of an algorithm and convert them into a series of visual images. Artistic aspects like composition, color, size and shape must be carefully controlled to focus the viewer's attention at all times. Unfortunately, the designer's time and energy usually get consumed by low-level system related issues long before getting to the real work of adjusting and improving an algorithm animation. We have developed GEF to provide a rapid turnaround environment for the development of algorithm animations. GEF simplifies the tasks involved in creating an animation and speeds up the development and tuning an animation. GEF w..

Spinopelvic parameters: lumbar lordosis, pelvic incidence, pelvic tilt, and sacral slope: what does a spine surgeon need to\ua0know\ua0to plan a lumbar deformity correction?

The pelvic incidence defines the amount of lordosis required in the lumbar spine, and a lumbar lordosis within 11° of the pelvic incidence defines alignment of the lumbo-pelvic region. Pelvic tilt is a compensatory mechanism that allows patients to achieve sagittal balance in the setting of decreased lumbar lordosis with the primary compensatory mechanisms being hip extension and knee flexion. Planning an adult lumbar deformity operation requires a comprehensive history and physical examination and thorough radiographic evaluation with the goal of restoring alignment between the pelvic incidence and lumbar lordosis and restoring a normal pelvic tilt

Defining similarity

We have developed an efficient way to determine the syntactic similarity of files and have applied it to every document on the World Wide Web. Using this mechanism, we built a clustering of all the documents that are syntactically similar. Possible applications include a "Lost and Found " service, filtering the results of Web searches, updating widely distributed web-pages, and identifying violations of intellectual property rights. Content

Early-term and Mid-term Histologic Events During Single-level Posterolateral Intertransverse Process Fusion With rhBMP-2/Collagen Carrier and a Ceramic Bulking Agent In a Nonhuman Primate Model: Implications for Bone Graft Preparation

Study Design: We used a non-human primate lumbar intertransverse process arthrodesis model to evaluate biological cascade of bone formation using different carrier preparation methods with a single dose of recombinant human bone morphogenetic protein-2 (rhBMP-2) at early time points.Objective: To examine early/mid-term descriptive histological and computerized tomographic events in single-level uninstrumented posterolateral non-human primate spinal fusions using rhBMP-2/ACS combined with ceramic bulking agents in three different configurations.Summary of Background Data: rhBMP-2 on an absorbable collagen sponge carrier (ACS) alone leads to consistent posterolateral lumbar spine fusions in lower-order animals; however, these results have been difficult to replicate in non-human primates.Methods: Twelve skeletally mature, rhesus macaque monkeys underwent single-level posterolateral arthrodesis at L4-L5. A hydroxyapatite (HA)/tricalcium phosphate ([beta]-TCP) ceramic bulking agent in three formulations was used in the treatment groups (n=3). When used, rhBMP-2/ACS at 1.5[medium shade]mg/cc (3.0[medium shade]mg rhBMP-2) was combined with 2.5[medium shade]cc of ceramic bulking agent per side. Animals were killed at 4 weeks and 12 weeks postoperative. Computerized tomography scans were performed immediately post-op and every 4 weeks until sacrifice. Sagittal histologic sections were evaluated for bone histogenesis and location, cellular infiltration of the graft/substitute, and bone remodeling activity.Results: Significant histological differences in the developing fusion appeared between the three rhBMP-2/ACS treatment groups at 4 and 12 weeks. At 4 weeks, bone formation appeared to originate at the transverse process and the intertransverse membrane. Cellular infiltration was greatest in granular ceramic groups compared with matrix ceramic group. Minimal to no residual ACS was identified at the early time point. At 12 weeks, marked ceramic remodeling was observed with continued bone formation noted in all carrier groups.Conclusions: At the early time period, histology showed that bone formation appeared to originate at the transverse processes and the intertransverse membrane, indicating that the dorsal muscle bed may not be the only location for bone formation. Histology also showed that the collagen carrier for rhBMP-2 is mostly resorbed by 4 weeks. Our results as well as previous literature indicate that ceramic bulking agents are needed to provide resistance to compression caused by paraspinal muscles on the fusion bed in the posterolateral environment. Histology showed that ceramic bulking agents may offer long-term scaffolding as well as a structure to supporting bone formation of the developing fusion mass

Exploring Trait Trade-Offs for Fungal Decomposers in a Southern California Grassland.

Fungi are important decomposers in terrestrial ecosystems, so their responses to climate change might influence carbon (C) and nitrogen (N) dynamics. We investigated whether growth and activity of fungi under drought conditions were structured by trade-offs among traits in 15 fungal isolates from a Mediterranean Southern California grassland. We inoculated fungi onto sterilized litter that was incubated at three moisture levels (4, 27, and 50% water holding capacity, WHC). For each isolate, we characterized traits that described three potential lifestyles within the newly proposed "YAS" framework: growth yield, resource acquisition, and stress tolerance. Specifically, we measured fungal hyphal length per unit litter decomposition for growth yield; the potential activities of the extracellular enzymes cellobiohydrolase (CBH), β -glucosidase (BG), β -xylosidase (BX), and N-acetyl- β - D -glucosaminidase (NAG) for resource acquisition; and ability to grow in drought vs. higher moisture levels for drought stress tolerance. Although, we had hypothesized that evolutionary and physiological trade-offs would elicit negative relationships among traits, we found no supporting evidence for this hypothesis. Across isolates, growth yield, drought stress tolerance, and extracellular enzyme activities were not significantly related to each other. Thus, it is possible that drought-induced shifts in fungal community composition may not necessarily lead to changes in fungal biomass or decomposer ability in this arid grassland