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Immune features that afford protection from clinical disease versus sterilizing immunity to Bordetella pertussis infection in a nonhuman primate model of whooping cough

Fri, 05/20/2016 - 3:30pm

The respiratory bacterial infection caused by Bordetella pertussis (whooping cough) is the only vaccine-preventable disease whose incidence has been increasing over the last 3 decades. To better understand the resurgence of this infection, a baboon animal model of pertussis infection has been developed. Naïve baboons that recover from experimental pertussis infection are resistant both to clinical disease and to airway colonization when re-challenged. In contrast, animals vaccinated with acellular pertussis vaccine and experimentally challenged do not develop disease, but airways remain colonized for 4-6 weeks. We explored the possibility that the IgG antibody response to pertussis infection is qualitatively different from antibodies induced by acellular pertussis vaccination.

IgG was purified from pertussis-convalescent baboons shown to be resistant to pertussis disease and airway colonization. Purified IgG contained high titers to pertussis toxin, pertactin, and filamentous hemagglutinin. This pertussis-immune IgG or control IgG was passively transferred to naïve, juvenile baboons before experimental airway pertussis inoculation. The control animal that received normal IgG developed a typical symptomatic infection including leukocytosis, cough and airway colonization for 4 weeks. In contrast, baboons that received convalescent IgG maintained normal WBC counts and were asymptomatic. However, despite remaining asymptomatic, their airways were colonized for 4-6 weeks with B. pertussis. All animals developed IgG and IgA anti-pertussis antibody responses. Interestingly, the clearance of B. pertussis from airways coincided with the emergence of a serum anti-pertussis IgA response.

These studies demonstrate that passive administration of pertussis-specific IgG from previously infected animals can prevent clinical disease but does not affect prolonged airway colonization with B. pertussis. This outcome is similar to that observed following acellular pertussis vaccination. Understanding immune mechanisms—other than IgG—that are capable of preventing airway colonization with B. pertussis will be critical for developing more effective vaccines to prevent whooping cough.

The Therapeutic Effects of per os Artemisinin Delivered as Dried Leaf Artemisia annuavs. Artesunate in Non-small Cell Lung Cancer

Fri, 05/20/2016 - 3:30pm

Artemisinin, the active component of Artemisia annua L. used to treat malaria, also has therapeutic efficacy against many types of cancer. Solubility issues led to development of more soluble semi-synthetic derivatives. Artesunate (ART), in particular, is a more soluble derivative of artemisinin and has profound cytotoxicity toward many types of tumor cells, but healthy cells are less sensitive. Artemisinin delivered per os as dried leaves, referred to as dried leaf artemisinin (DLA), was shown in rodent studies to improve bioavailability by more than 40-fold. ART has been widely studied for its anti-cancer properties, but it has yet to be shown if DLA also improves therapeutic efficacy. As A. annua produces a wide array of phytochemicals with anti-cancer activity other than artemisinin, it is reasonable to expect DLA may provide a more potent therapeutic. Using two non-small cell lung cancer cell lines, PC-9 and H1299, artemisinin delivered as DLA effectively reduced viability with 24h IC50 values of 56.3 and 77.5 µM for PC-9 and H1299, respectively, as determined by MTT assay. For PC-9 cells, this was a 2.5-fold improvement in the 24h IC50 value for ART at 142.9 µM. However, for the H1299 cells, ART at 60.6 µM was better than DLA by about 25%. Ongoing studies are comparing the mechanism of action of DLA and ART on these two cell lines and will analyze markers for apoptosis, proliferation and metastatic migration and invasion. Xenograft models also will be used to compare in vivo efficacy of DLA and ART on tumor reduction. These studies will help us further understand the anti-cancer effects of artemisinin when delivered per os as dried plant leaves.

The Effect of Oral Antibiotics on the Development of Community Acquired Clostridium Difficile Colitis in Medicare Beneficiaries

Fri, 05/20/2016 - 3:30pm

Clostridium difficile infection (CDI) is increasingly prevalent among community dwelling Americans. Older Americans are particularly vulnerable to community-acquired Clostridium difficile (CACD), in part to increasing use of antibiotics. We studied the association between outpatient antibiotics and CACD among Medicare beneficiaries.

Case-control study utilizing a 5% sample of Medicare beneficiaries (2009-2011). Patients with CACD severe enough to warrant hospitalization were identified by a primary diagnosis code for CDI and no exposure to a healthcare environment within 90-days of admission. 1,514 CACD cases were matched to ten controls each on birth year and sex. Potential controls with exposure to healthcare environment were excluded. Outpatient oral antibiotic exposure was classified into three groups: ≤30 days, 31-60 days, or 61-90 days prior to case subject’s index admission. Metronidazole and Vancomycin were excluded because they are used to treat CDI. Multivariable models were utilized to determine the independent effect of antibiotics on the development of CACD while controlling for several patient associated characteristics.

Cases of CACD had more outpatient antibiotic exposure in each time period examined: ≤30 days = 40.0% vs 8.4%; 31-60 = 10.7% vs 5.0%; and 61-90 = 5.5% vs 4.4% (all p-values < 0.05). Subjects exposed to antibiotics ≤30 days prior to admission had a markedly higher risk of being admitted with CACD compared with those not exposed (OR 8.09, 95% CI 7.13, 9.19). Similarly, subjects taking antibiotics 31-60 days and 61-90 days prior to admission had increased risk of CDI admission (OR 3.65, 95% CI 3.02, 4.41) and (OR 2.06, 95% CI 1.61, 2.63) respectively.

Recent exposure to outpatient oral antibiotics increases the risk of CACD among community dwelling elderly with the risk persisting as long as 90 days after exposure. Inappropriate antibiotic usage must be minimized and older Americans who require outpatient antibiotic treatment may warrant close observation for signs of CDI.

Advanced MRI Center: a 3 Tesla Magnetic Resonance system for preclinical, translational and clinical imaging studies

Fri, 05/20/2016 - 3:30pm

The Advanced MRI Center, located in the UMass Medical School building, is a research core facility providing the latest magnetic resonance imaging and spectroscopy capabilities to UMass scientists. It is equipped with a Philips Achieva 3.0T X-series whole-body scanner and radiofrequency coils for studying all organs of the human body, and small and large animals, such as mice, rats, rabbits, dogs, sheep and non-human primates. The center also includes a radiofrequency coil lab, a nurses’ station, two patient holding rooms and two patient changing rooms.

The Center’s specialized techniques are able to elucidate functional, physiological and biochemical information from all organs of the body.

The 3.0 Tesla system features the Quasar Dual gradient system with industry leading performance specifications, that allow high-level diffusion tensor imaging and functional MRI (fMRI) applications in humans, and high resolution imaging studies in small animal studies. A fMRI stimulus delivery system, a MRI compatible goggle set with eye tracking system, microphone and earphones are available for facilitating fMRI studies.

Small animal monitoring and gating system and an MR compatible Anesthesia system with heater and ventilator option are also available.

The 3.0T MR system is also equipped with a Multi-nuclear spectroscopy system, which provide the ability to perform 13C, 31P, 7Li, 23Na and other nuclei spectroscopy and imaging. Technical and clinical expertise for collaborative research is also provided.

Rational Design of an Epitope-Based Hepatitis C Virus Vaccine

Fri, 05/20/2016 - 3:30pm

Despite improving treatment methods and therapeutic options, hepatitis C virus (HCV) remains a major global disease burden, and a vaccine would help greatly in reducing its incidence. Due to its extremely high sequence variability, HCV can readily escape the immune response, thus a vaccine must elicit an immune response toward conserved, functionally important epitopes.

Using structural data of the broadly neutralizing antibody HCV1 in complex with a conserved linear epitope from the HCV E2 protein (aa 412-423, referred to as epitope I or domain E), we performed structure-based design to generate vaccine immunogens to induce antibody responses to this epitope. Designs selected for immunological characterization included a stabilized minimal epitope structure based on a defensin protein, as well as a bivalent vaccine featuring two copies of epitope I on the E2 surface. In vivo studies confirmed that these designs successfully generated robust antibody responses to this epitope, and sera from vaccinated mice neutralized HCV. In addition to presenting several effective HCV vaccine immunogens, this study demonstrates that induction of neutralizing anti-HCV antibodies is possible using an epitope-based vaccine, providing the basis for further efforts in structure-based vaccine design to target this and other critical epitopes of HCV.

Advancing Medical Device and Biotech Innovations

Fri, 05/20/2016 - 3:30pm

M2D2 is a UMass Lowell – UMass Medical School Worcester initiative that helps entrepreneurs move new medical device and biotech ideas from patent to production and offers early-stage inventors and established companies easy, affordable and coordinated access to world-class researchers and resources at both the Lowell and Worcester campuses.

UMass Lowell and UMass Worcester extend use of engineering and scientific resources to M2D2 companies. These core resources are available to researchers by using the research services agreement. The use of UMass Lowell and UMass Worcester interns and faculty is an enormous benefit to an emerging medical device or biotech company.

UMass Worcester’s campus offers access to core research supports and highly trained personnel to efficiently conduct animal or clinical studies across the life cycle of projects.

UMass Lowell has two M2D2 facilities with private and shared wet lab space, equipment, office space and conference rooms. It offers business and medical feasibility assessments, product development, medical and clinical pathway assistance, SBIR and STTR research partnerships and access to capital.

M2D2 was established with seed funding from the UMass President’s Office, the Mass Life Sciences Center and the Commonwealth of Massachusetts.

Predisposed Health Conditions of Children Exposed to Methamphetamine In Utero

Fri, 05/20/2016 - 3:30pm

Methamphetamine (MA) use and abuse is a growing problem worldwide [United Nations World Drug Report]. It is common knowledge that MA use affects not only the user, but also friends, family, and the communities close to them [NIDA]. One area of impact that is lacking sufficient study is the effects of MA use by expectant mothers on her child later in life. That is to say, a child who was exposed to MA in utero may be more likely than an unexposed fetus to have predispositions to a variety of health conditions. After an extensive PubMed database search, it is apparent that research is limited on the childhood illnesses and health conditions related to fetal exposure to MA. Some research, suggests a potential link between a fetus exposed to MA and the development of attention deficit hyperactivity disorder (ADHD) later in childhood. [Kiblawi, et. al.; Legasse, et. al.] The lack of available research warrants an exhaustive database search and a retrospective epidemiological study to better understand the health risk of children exposed to MA. The knowledge gained from this work can inform healthcare providers and public health officials when intervening to reduce MA use and addiction.

Lipoaspirate and Adipose Stem Cells as Potential Therapeutics for Chronic Scars

Fri, 05/20/2016 - 3:30pm

Introduction: Burn injuries can lead to hypertrophic or keloid scars, causing pain and long lasting mobility issues. Current therapies are often unsatisfactory, costly, or morbid. Prior studies suggest adipose derived stem cells (ADSCs) and lipoaspirate can improve scar outcomes of acute thermal wounds. Clinical reports suggest lipoaspirate and ADSCs can improve chronic burn scar remodeling. However, this has not been extensively studied in animal models. We sought to determine if adipose tissue can improve chronic scar remodeling and to compare the effects of ADSCs and processed lipoaspirate.

Methods: 50 CD1 nu/nu athymic mice received a standardized deep partial-thickness thermal burn. Scars matured for 6 weeks. Photographs and perfusion measurements by hyperspectral imaging (HSI) were taken over the entire study. Lipoaspirate and ADSCs (SVF and ex-vivo culture with flow cytometry confirmation) were obtained from a discarded human pannus specimen. After 6 weeks, animals received a 0.6cc subcutaneous graft beneath the scar of either: human lipoaspirate processed with the Coleman technique, high-dose (106) hADSCs in Matrigel, low-dose (104) hADSCs in Matrigel, Matrigel only, or not injected (n=10 per group). At 10 weeks, animals were sacrificed and scar tissue was harvested for histological and molecular analysis.

Results: HSI oxygenated hemoglobin values in lipoaspirate treated scars increased significantly more compared to 6-week pre-treatment baseline than all other groups (p < 0.05). Planimetry analysis showed reduction in wound area in lipoaspirate treated mice compared to control groups (p < 0.01). Blood vessel density quantification on Masson’s trichrome stains suggests increased density in lipoaspirate treated scars versus controls (p < 0.01).

Conclusion: HSI, blood vessel density, and scar analysis suggest improvement in lipoaspirate treated scars compared to controls. Preliminary molecular data offers some insight to this trend. No effect was seen with ADSCs at either concentration at the analyzed timepoints. Molecular analyses are ongoing to investigate cellular mechanisms in regulating scar remodeling.

Angina Characteristics as Predictors of Trajectories of Quality of Life Following Acute Coronary Syndrome in the Transitions, Risks and Actions in Coronary Events-Center for Outcomes Research and Education cohort (TRACE-CORE)

Fri, 05/20/2016 - 3:30pm

BACKGROUND: To describe longitudinal trajectories of health-related quality of life (HRQoL) after hospitalization with an acute coronary syndrome (ACS), their associations with baseline angina characteristics, and associations with anxiety, depression, and cognitive impairment.

METHODS: TRACE-CORE participants (N=1,613) completed the SF-36 during hospitalization for ACS and 1, 3, & 6 months post-discharge. Latent growth curves identified trajectories of physical and mental components of HRQOL (MCS and PCS) and sequential multiple logistic regression estimated associations between trajectories and angina characteristics.

RESULTS: Participants (N=1613) had mean age 63.3 (SD 11.4) years, 33.0% female, and 78.2% non-Hispanic white. We identified 2 MCS trajectories: AVERAGE and IMPAIRED HRQoL. The majority of participants (81.0%) had AVERAGE MCS at baseline (mean MCS 53.6) and slight improvement in scores over time. A minority (19.0%) had IMPAIRED HRQoL at baseline (mean MCS 36.7) and slight improvement in scores over time. We identified 2 similar PCS trajectories with similar patterns of scores over time: AVERAGE (71.1%) and IMPAIRED (28.9%) HRQoL at baseline. Adjusting for demographics & comorbidities, patients with less severe baseline angina were more likely to have AVERAGE MCS (odds ratio [OR]/10 unit change in severity 1.1) and PCS (OR 1.1) trajectories, and similarly for less frequent angina (MCS OR 1.2; PCS OR 1.3). The associations of MCS trajectory with severity and frequency lost significance after adjusting for psychosocial factors, whereas the PCS associations remained significant [All p < 0.05 unless noted].

CONCLUSIONS: About 1/3 of patients exhibited impaired 6-month HRQoL trajectories, which can be predicted by angina characteristics. Psychosocial factors may explain the prediction of mental, not physical, trajectories. Interventions to improve HRQoL after ACS should consider psychosocial factors and angina.

6-Month Change in Pain and Function by Pre-Operative Pain and Function among Patients Selected for Total Knee Replacement in the United States

Fri, 05/20/2016 - 3:30pm

Background/Purpose: The increase in total knee replacements (TKRs) between 1979 and 2006 is staggering. Debate is growing regarding the appropriate utilization of TKRs. We examined pain, function, quality of life (QOL), and satisfaction at 6-month post-surgery by pain and function at time of surgery.

Methods: Data came from the nationally representative FORCE-TJR cohort of patients from 150 surgeons. Participants had primary, unilateral TKRs due to osteoarthritis between 2011 and 2014. Their knee pain (KOOS), physical functions (SF36), and QOL were measured at pre- and 6 months post-surgery. We classified patients as having high or low pre-operative pain (KOOS Pain < 70 vs. ≥70), low or high pre-operative physical function (SF-36 PCS < 40 vs. ≥40), and grouped as: 1) Low pain-High function (LP-HF), 2) Low pain-Low function (LP-LF), 3) High pain-High function (HP-HF), and 4) High pain-Low function (HP-LF). We compared pre- and post-operative changes in pain and function scores among the four groups.

Results: Of 4,563 participants, 5% had pre-operative LP-HF and 75% HP-LF. By 6-month post-surgery, 85% of LP-HF patients reported no change and 4% reported worse symptoms; the HP-LF group had 18% no change and 52% with large improvement. For function in the LP-HF group, mean 6-month change (SD) was 2.6 (7.8), with post-operative mean of 50.0 (7.4). Mean change for the HP-LF group was 11.9 (9.0), with post-operative mean of 42.0 (9.5). For pain score in the LP-HF group, mean 6-month change was 8.3 (14.6), with post-operative mean (SD) of 88.9 (13.0). The HP-LF group had average improvement of 37.2 (19.7), and post-operative mean of 79.9 (17.3). QOL was better among the LP-HF than HP-LF groups; satisfaction was similar.

Conclusion: The majority of patients had appropriate TKR utilization and achieved large improvement in pain and function. Patients with pre-operative LP-HF achieved the smaller mean change, but better absolute outcomes.

Total hip arthroplasty and mental health status

Fri, 05/20/2016 - 3:30pm

Purpose. Total hip arthroplasty (THA) effectively restores function and alleviates pain in patients with end-stage hip osteoarthritis. Pain affects mood through its effect on disability and fatigue. Few studies have examined mental health as a consequence of pain or function after THA. We assessed change in mental health 1-year post-surgery, and examined whether change in pain and function predict change in mental health.

Methods. We used data from a prospective THA registry that began in 1996 at a large public Geneva University hospital. We included surgeries performed 2010 and 2012-2014, with demographic information, body mass index (BMI), co-morbidities, baseline and 1-year post-surgery WOMAC pain and function scores, and the SF-12 mental health component score (MCS). The pain, function, and MCS scores were normalized and ranged from 0-100; increasing score indicating better outcome. We calculated descriptive statistics, and used multivariable linear regression to predict 1-year change in MCS.

Results. Of 610 participants, mean (SD) age was 68.5 (11.8) years and BMI of 26.9 (4.9), 53% were women. Mean MCS was 44.7 (11.2) at baseline and 47.5 (10.5) at 1-year post surgery; average 1-year change was 2.8 (95% CI 1.9-3.6). WOMAC pain score was 39.6 (18.3) at baseline and 83.8 (20.4) at 1-year post surgery; 1-year change was 44.2 (95% CI 42.4-46.0). Corresponding WOMAC function was 40.2 (18.8) and 78.3 (22.1); 1-year change was 38.1 (95% CIs 36.2-40.0). On average, a 10-point increase in 1-year change in pain score was associated with a 0.7 point increase in the adjusted 1-year change in MCS (95% CI 0.2-1.1). The change in function was associated with a 0.9 point increase in 1-year change in MCS (95% CI 0.5-1.4).

Conclusion. Mental health significantly improved from baseline to 1-year post-surgery. Patients whose pain and function scores improved the most had also the greatest improvement in mental health.

Human monoclonal antibodies to Plasmodium falciparum circumsporozoite protein for transient passive protection of malaria travelers to endemic areas

Fri, 05/20/2016 - 3:30pm

Plasmodium falciparum, is a protozoa that causes over 214 million cases of Malaria worldwide and the World Health Organization reported an estimated 438,000 deaths attributed to malaria in 2015. Current prevention strategies have reduced malaria cases but they are either costly, have poor efficacy or resistance has begun to develop. There is a global need for an effective pre-exposure prophylaxis treatment.

The leading Malaria vaccine candidate is RTS,S which contains a monovalent Plasmodium falciparum circumsporozoite protein (CSP). The goal of this vaccine is to induce anti-CSP antibodies that would block sporozoite invasion of hepatocytes and thereby hinder parasite development into a blood-stage infection that causes malaria morbidity and mortality. Antibodies isolated from individuals who have received the RTS,S vaccine have been shown to prevent infection of hepatocytes, suggesting that CSP antibodies could be used prophylactically. However, phase III trial results of the vaccine have shown underwhelming efficacy in children.

Growing resistance to transient protection strategies for travelers and low efficacy in vaccine trials suggest there is a need for a new treatment strategy. The generation of CSP specific human monoclonal antibodies (mAbs) would be useful as prevention especially for individuals that are temporarily exposed to Malaria in endemic regions such as travelers or military personnel.

Isolation and production of therapeutic mAbs traditionally utilizes a handful of techniques including antibody engineering, phage display or hybridoma generation from transgenic mice. We have sorted antigen-specific memory B-cells from the peripheral blood of children naturally infected with malaria to isolate CSP-specific memory B-cells. These cells were individually sorted and PCR was performed to amplify antibody variable regions of the B-cell’s antibody mRNA. Samples that produced heavy and light chain antibody sequence were cloned and transiently expressed. We plan to characterize these mAbs for binding and neutralization of CSP to identify functional therapeutic mAbs.

The Use of Complementary and Alternative Medicine (CAM) and Imported Medications by Brazilians in Massachusetts

Fri, 05/20/2016 - 3:30pm

Background: The use of CAM products and imported pharmaceuticals has been rising in the United States. These practices are particularly common in Latino populations. This descriptive study sought to investigate the use of pharmaceuticals imported from Brazil and CAM products by the Brazilian population in Massachusetts.

Methods: A brief anonymous survey was administered online via social media and in paper during visits to Brazilian establishments to a sample of first-generation Brazilian immigrants residing in Massachusetts. The survey questionnaire was administered in Portuguese and explored participants’ use of CAM products and imported pharmaceuticals as well as patient disclosure of use to physician.

Results: 595 surveys responses were collected and a total of 540 surveys were included in the statistical analysis. 59.1% of respondents reported having used imported medications from Brazil during their time of residence in the US. The most commonly used classes of imported medications were analgesics and antibiotics. 31.5% of participants reported use of CAM products; most commonly for cold-like symptoms. CAM products and imported medications were most often obtained through friends or relatives who brought them from Brazil. 63.9% of respondents did not inform their physician about their use of imported medications and/or CAM products. The most common reason for not reporting was because the doctor did not ask.

Conclusions: To improve care of Brazilian immigrants, it is essential that US physicians ask patients about the use of imported medications and CAM products. Familiarity with the most commonly used products is important for patient education regarding efficacy, toxicity, and possible drug interactions.

Physiological and Social Stress on Cognitive Performance

Fri, 05/20/2016 - 3:30pm

Humans are highly social creatures and this provides us with a number of benefits, such as protection and support, but it also brings new avenues for stress from social sources. Basic and translational neuroendocrine research has yielded a rich set of findings and a general understanding of how acute and chronic stress can result in reduced health, earlier aging, and earlier death. Although stress can be indexed by level of cortisol, the major stress hormone in humans, many interrelated physiological systems are involved in a stress response, including the cardio and vascular systems. Research toward greater understanding of stress buffering mechanisms holds value for improved human health in the face of entrenched social stressors.

In particular, acute and chronic stress have consistently been found to impair cognitive performance, Many adults in high stress environments also face a changing social landscape during college years: changes in living partners, less control over noise, sleep, exercise, and nutrition. In this pilot investigation, we are interested in measuring the influences of acute stress on cognitive performance and whether social support, a factor that is modifiable, would be protective on the multi-systems relationships between stress and cognition.

Broadly, we found (1) that higher levels of cortisol measured in saliva was associated with a faster return to resting levels of salivary cortisol (a measure of flexible, adaptive functioning of the central HPA stress system) after the stressor is removed and may also be associated with lower cortisol in the initial response to the stressor. In parallel, we found (2) that higher levels of cortisol were associated with impaired cognitive performance after the stress task, (3) finally, we found that those reporting high social support showed faster recovery to baseline in the cardiovascular systems and greater social support produced some buffering of stress response on their post-stress cognitive performance.

Terpenes as ‘resistance-busting” anthelmintic drug

Fri, 05/20/2016 - 3:30pm

There is an urgent need for new therapies for parasitic helminthic diseases affecting 1.5-2 billion people worldwide due to the threat of wide-spread resistance development to existing treatments and due to problems of incomplete efficacies.

Terpenes are plant secondary metabolites and major essential oil constituents. Historically, the terpene thymol was successfully used to cure hookworm infections in the 1900’s. Although effective, large doses were needed and thymol treatment had significant side effects. Because free terpenes are absorbed in the stomach, less than 10% of oral terpenes entered the site where the parasites live. To overcome these problems we have developed microparticle encapsulated terpenes and enteric coated terpene capsules.

We screened 20 terpenes for anthelmintic activity in vitro against adult stages of the hookworm and whipworm parasitic nematodes Ancylostoma ceylanicum and Trichuris muris. Here we will present results of this work, which shows the promising potential for some terpenes as pan-nematode anthelmintics. This work has allowed us to classify terpenes into at least two groups based on their in vitro killing kinetics. We have also shown that some terpenes are effective against an albendazole-resistant Caenorhabditis elegans strain suggesting that terpenes may play an important role in overcoming helminthic drug resistance. We will also present our work on optimizing lead terpene formulations in vitro and in vivo in animal models of parasitic nematode infection in order to overcome the challenges and realize the potential of “resistance-busting” terpene-based anthelmintic therapies.

Emergency Medicine Providers Systematically Underestimate Their Opioid Prescribing Practices

Fri, 05/20/2016 - 3:30pm

Background: Opioid misuse is a known public health problem, nationwide and in Massachusetts. The Massachusetts Hospital Association (MHA) developed recommendations to address opioid prescribing in the ED setting, and UMassMemorial Health Care recently implemented a system-wide opioid practice guideline mirroring the MHA policy. Little is known about methods to influence behavior change among ED providers related to opioid prescribing practices. Guideline implementation provided a unique opportunity for a natural experiment related to prescribing patterns, and we hypothesized that a simultaneous experimental intervention to provide clinicians with their individual prescribing data would alter their practices beyond any effect achieved solely by being subject to the new guidelines.

Methods: As part of an ongoing, prospective, randomized trial of an intervention hypothesized to influence providers’ opioid prescribing, we developed a survey instrument consisting of graphical depictions of the distributions of three measures of opioid prescribing among all ED providers at four UMass-affiliated EDs (attending and resident physicians and advanced practice providers). Clinicians randomized to the intervention arm were asked to identify his/her perceived position on each distribution. We compared each provider’s self-perception to their actual decile.

Results: Fifty-one providers were randomized to the intervention arm. Forty-eight completed the survey (94%). Providers underestimated their decile of opioid prescriptions per hundred total prescriptions by a median of one decile (p=0.0399 for difference from zero). Attendings underestimated their decile of percentage of patients dispositioned with an opioid prescription by a median of two deciles (p=0.0292), while residents did not exhibit a significant difference. Providers showed systematic disagreement with their raw number of prescriptions for extended-release opioid formulations (kappa -0.18), underestimating by a median of one.

Conclusions: Based upon three measures of ED opioid prescribing, providers’ self-perceptions of their practices systematically underestimated their actual prescribing, which likely has implications related to efforts to influence clinician behavior change.

Correlates of hyaluronic acid and corticosteroid injections among patients with radiographically confirmed osteoarthritis

Fri, 05/20/2016 - 3:30pm

Objective: Despite the rapid proliferation of hyaluronate (HA) and corticosteroid (CO) injections and clinical guidelines regarding their use in osteoarthritis (OA), information on the characteristics of people receiving them is scarce. We described use of injections among adults with radiographically confirmed knee OA and identified correlates of injection use.

Methods: We used publicly available data from Osteoarthritis Initiative and included participants with ≥ one radiographically confirmed knee OA (Kellgren-Lawrence grade (K-L) > 2) at baseline. We matched 415 participants reporting HA and/or CO during the 6 month before one of the first 7 annual follow-up assessments to 1,841 non-injection users by randomly selecting a study visit to match the distribution observed in the injection users. Multinomial logistic regression models identified correlates of injection use including sociodemographics and clinical/functional factors.

Results: Injections were common (16.9% -year 1, 13.7% -year 2, 16.6 % -year 3, 13.5% - year 4, 15.9% -year 5, 13.5 % -year 6 and 9.9% -year 7) with corticosteroid injections most common (68.4%). HA and CO were more commonly reported by those with higher income (e.g. adjusted Odds Ratio (aOR) HA > $50k versus < $25k: 3.63; (95% CI: 1.20-10.99)) and less common among blacks (aOR HA: 0.19; 95% CI: 0.06-0.55). Greater K-L grade (grade 4 versus 2) was associated with increased odds of HA (aOR: 4.79; 95% CI: 2.47-9.30), CO (aOR: 1.56; 95% CI: 1.04-2.34), or both (aOR: 4.94; 95% CI: 1.99-12.27).

Conclusion: Hyaluronic acid or corticosteroid injections are associated with higher socioeconomic positioning and indicators of greater disease severity.

Using Interviews to Understand Patients’ Post-operative Pain Management Educational Needs Before and After Elective Total Joint Replacement Surgery

Fri, 05/20/2016 - 3:30pm

Objective: To better understand the education needs of patients electing to have TJR in managing their pain in the post-operative period after discharge from the hospital.

Methods: An exploratory, descriptive, qualitative design. Convenience sample of people who reported that they had not received information about pain management prior to TJR surgery were recruited from 9 surgeon practices in 8 states to participate in telephone interviews, utilizing open-ended questions. Questions included: recollection of pre-op class attended and content; experiences with surgical pain after surgery and how it was managed; experiences with pain medicine; experience using non-medicine related pain reduction methods; suggestions for delivery of pain management information. Interviews were recorded and transcribed. Data were categorized using content analysis techniques.

Results: Seventeen patients were interviewed. Although all remembered attending a pre-operative class prior to their joint replacement surgery, none remembered receiving information during that class about managing pain once they were discharged. All had been prescribed an opioid for pain management post-operatively; however no patients reported receiving any information regarding use of the medication other than the information on the pill bottle. Many had concerns regarding the use of opioids to control their pain, including side effects, such as constipation and the risk of addiction. The most common non-medicine method used to manage pain was the use of ice. Participants believed that information about pain management, including both non-medicine approaches and instructions for taking opioids would be helpful and should be delivered at multiple time points, including pre-operatively, at discharge, and within the first few days after discharge.

Conclusion: With trends toward shorter hospital stays, home based pain management is a priority. Understanding the pain management education needs of patients considering elective TJR could inform interventions for this population as well as provide insight into the needs of other patients undergoing surgery.

Effective Pain Information Pre-operatively is Associated with Improved Functional Gain after Total Joint Replacement

Fri, 05/20/2016 - 3:30pm

Objective: We evaluated receipt of pre-operative pain management education in a national prospective cohort on post-operative pain and function.

Methods: Preoperative, 2 week and 6 month postoperative data from a nationally representative cohort of 1404 primary unilateral TJR patients with a date of surgery between May 2011 and December 2014. Data included demographics, comorbid conditions, operative joint pain severity (HOOS/KOOS), musculoskeletal disease burden, physical function (SF36 PCS), and mental health (SF36 MCS). At 2 weeks post-op, patients were asked if they had received information prior to surgery about pain management options and if so, how helpful the information was. Additionally, patients were asked about use of non-medication methods to relieve operative joint pain. Descriptive statistics were performed.

Results: One third reported not receiving information about pain management; an additional 11% did not find it helpful. There were no differences pre-operatively in demographics, comorbid conditions, operative joint pain severity, musculoskeletal disease burden, SF36 PCS and MCS between those who received information and those who did not. Patients who received information about pain management options were more likely to use non-medication methods to relieve operative joint pain (p< 0.000). They reported less current pain (p = 0.02) and maximum pain (p = 0.03) in their operative joint at 2 weeks post-op. At 6 months post-op, patients who reported not receiving information about pain management had statistically lower physical function scores that those receiving information (p = 0.04). There was no difference in HOOS/KOOS pain scores 6 months post-op.

Conclusion: More than 40% of TJR patients in this study reported that they did not receive or received unhelpful information regarding post-op pain management options, highlighting a need for more consistent patient education. In this study, the lack of pain management information appears to negatively impact 6 month post-operative function.

Does the Indication for Breast Surgery Impact Surgical Outcomes? A Contemporary Analysis of the ACS-NSQIP Database

Fri, 05/20/2016 - 3:30pm

Background. There is limited data about whether perioperative outcomes differ based on the indication for breast surgery. Herein we aim to assess if breast surgery for prophylaxis, compared to that for malignancy, impacts surgical outcomes.

Methods. All women who underwent simple or subcutaneous mastectomy were identified from the 2007-2012 ACS-NSQIP database. Patients were identified by their ICD-9 codes and categorized into two groups. Group 1 consisted of patients diagnosed with breast cancer or carcinoma in situ; group 2 consisted of patients diagnosed with a genetic predisposition to malignant neoplasm of the breast (i.e., BRCA mutation). Demographic and preoperative variables were compared between groups and outcome variables. Outcome variables were analyzed using age- and operative time-adjusted logistic regression models.

Results. 30,803 patients were identified. Group 1 consisted of 30,644 (99.5%) patients diagnosed with malignancy; group 2 consisted of 159 (0.5%) who underwent prophylactic surgery. In univariate analyses, those undergoing prophylactic surgery were significantly younger (p < 0.01). There were no other preoperative differences between groups. When adjusted, the prophylactic group demonstrated a greater risk of DVT (p = 0.03). There were no differences in mortality, superficial/deep/organ space infections, UTI, wound dehiscence, or MI.

Conclusion. In this analysis of a national cohort of breast surgery patients, those undergoing prophylactic surgery due to a genetic predisposition had a greater risk of perioperative DVT, compared to those who underwent surgery for a diagnosis of malignancy. This data may allow for improved perioperative management of patients to prevent DVT development and their devastating consequences.