This review will describe the biological and behavioral aspects of nicotine addiction as it develops during adolescence and advances over a lifetime. Symptoms of physical nicotine dependence typically appear when adolescents are smoking only a few cigarettes each month. Physical dependence develops through a set sequence of symptoms that correlate with changes in brain structure in addiction circuits. Smokers often describe their symptoms of physical dependence as "wanting," then "craving," and eventually "needing" to smoke. These symptoms appear whenever the smoker goes too long without smoking. The intensity of abstinence-induced craving correlates with spontaneous activation of addiction-related networks in the brain as illustrated in the graphical abstract of this article. Initially, smoking a single cigarette can keep withdrawal symptoms at bay for weeks, but as tolerance develops, cigarettes must be smoked at progressively shorter intervals to suppress withdrawal symptoms. The physiologic need to repeatedly self-administer nicotine at shorter intervals explains a full spectrum of addictive symptoms and behaviors.
In a neighborhood near you: how community health workers help people obtain health insurance and primary care
Implementing the health insurance mandate of the Patient Protection and Affordable Care Act (ACA), signed into law in 2010, will require states to reach, educate, and successfully enroll individuals and families who have had little experience with health coverage. The uninsured are likely to require considerable individualized application and enrollment support. Consumer advocates believe there is a need for ongoing support so that the newly insured retain their coverage, navigate their way effectively through the health care system, and engage in wellness and prevention activities. As many states prepare to enroll millions of low-income uninsured Americans, the experience of Community Health Workers (CHWs) in Massachusetts can inform outreach and enrollment efforts across the country.
The impact of prior authorization on buprenorphine dose, relapse rates, and cost for Massachusetts Medicaid beneficiaries with opioid dependence
OBJECTIVE: To assess the impact of a 2008 dose-based prior authorization policy for Massachusetts Medicaid beneficiaries using buprenorphine + naloxone for opioid addiction treatment. Doses higher than 16 mg required progressively more frequent authorizations.
DATA SOURCES: Mediciaid claims for 2007 and 2008 linked with Department of Public Health (DPH) service records.
STUDY DESIGN: We conducted time series for all buprenorphine users and a longitudinal cohort analysis of 2,049 individuals who began buprenorphine treatment in 2007. Outcome measures included use of relapse-related services, health care expenditures per person, and buprenorphine expenditures.
DATA COLLECTION/EXTRACTION METHODS: We used ICD-9 codes and National Drug Codes to identify individuals with opioid dependence who filled prescriptions for buprenorphine. Medicaid and DPH data were linked with individual identifiers.
PRINCIPAL FINDINGS: Individuals using doses > 24 mg decreased from 16.5 to 4.1 percent. Relapses increased temporarily for some users but returned to previous levels within 3 months. Buprenorphine expenditures decreased but total expenditures did not change significantly.
CONCLUSION: Prior authorization policies strategically targeted by dose level appear to successfully reduce use of higher than recommended buprenorphine doses. Savings from these policies are modest and may be accompanied by brief increases in relapse rates. Lower doses may decrease diversion of buprenorphine.
Variation in long-term antipsychotic polypharmacy and high-dose prescribing across physicians and hospitals
OBJECTIVES: This study had two aims: to measure the prevalence of long-term prescribing of high doses of antipsychotics and antipsychotic polypharmacy in a large Canadian province and to estimate the relative contributions of patient-, physician-, and hospital-level factors.
METHODS: Government hospital discharge, physician, and pharmaceutical claims data were linked to identify individuals with schizophrenia who in 2004 had antipsychotics available to them for at least 11 months. Individuals on a high dose throughout that period, as well as individuals on multiple concurrent antipsychotics (polypharmacy), were identified. Logistic and generalized linear mixed models using patient-, physician-, and hospital-level predictors were estimated.
RESULTS: Among the 12,150 individuals identified, 11.9% were on a high dose and 10.4% on antipsychotic polypharmacy continually, with 3.7% in both groups. After adjustment for potential confounders, analyses showed that systematic propensity for physicians to prescribe high doses accounted for 10.9% of the remaining unexplained variance, and physicians as a group who prescribed high doses across a hospital or psychiatry department accounted for 3.0%. For antipsychotic polypharmacy the corresponding percentages were 9.7% and 6.2%. Even after adjustment, the variation in high-dose prescribing and antipsychotic polypharmacy remained substantial.
CONCLUSIONS: Long-term high-dose and antipsychotic polypharmacy prescribing appeared partly driven by some physicians' and some hospitals' propensities to prescribe in this way independently of patient characteristics. Given the weight of the evidence against high-dose prescribing and antipsychotic polypharmacy, measures addressed to physicians and hospitals most likely to prescribe high doses, antipsychotic polypharmacy, or both should be considered.
OBJECTIVE: Despite the large number of Latinos living in the United States, little research has evaluated the effectiveness of different vocational rehabilitation programs for individuals with severe mental illness in this rapidly growing minority population. This article presents a secondary analysis of a randomized, controlled trial comparing supported employment with 2 other vocational rehabilitation programs in 3 ethnic/racial groups of participants with severe mental illness: Latinos, non-Latino African Americans, and non-Latino Whites.
METHOD: The data were drawn from a previously published randomized, controlled trial comparing supported employment with standard vocational rehabilitation services and a psychosocial clubhouse program in persons with severe mental illness (Mueser et al., 2004), including 64 Latinos, 91 non-Latino African Americans, and 43 non-Latino Whites. Comparisons were made between the 3 groups at baseline on demographic characteristics, clinical and psychosocial functioning, and quality of life. Within each ethnic/racial group, competitive employment and all paid employment outcomes were compared between the 3 vocational rehabilitation programs over the 2-year study period.
RESULTS: At baseline, the Latino participants had lower levels of education and disability income, were less likely to have worked competitively over the previous 5 years, had more severe symptoms, and worse psychosocial functioning than the non-Latino African American or non-Latino White participants. Latinos randomized to supported employment had better competitive and all-paid work outcomes than those assigned to either standard services or the psychosocial clubhouse program, similar to the non-Latino consumers. Rates of competitive work for consumers in supported employment were comparable across all 3 racial/ethnic groups.
DISCUSSION: Supported employment is effective at improving competitive work in Latinos with severe mental illness. Efforts should be made to increase access to supported employment in the growing population of Latinos with severe mental illness.
Policy interventions that attempt to influence patient care can be hard to implement and their desired outcomes can be slow to achieve. The efforts of the Centers for Medicare and Medicaid Services (CMS) to reduce preventable infections by withholding payment for additional expenses related to catheter-associated urinary tract infections (CAUTI) illustrate this challenge clearly.
Co-occurring risk factors for arrest among persons with opioid abuse and dependence: implications for developing interventions to limit criminal justice involvement
Persons who abuse or are dependent on opioids are at elevated risk for arrest. Co-occurring behavioral health problems may exacerbate that risk, although the extent of any such increase has not been described. This study examines such risk factors among 40,238 individuals with a diagnosis of opioid abuse or dependence who were enrolled in the Massachusetts Medicaid program in 2010. Medicaid data were merged with statewide arrest data to assess the effects of co-existing mental illness, substance abuse, and previous arrests on arrest during 2010. Persons with serious mental illnesses (psychotic and bipolar disorders) and those with two or more pre-2010 arrests had significantly increased greater odds of arrest. We believe this to be the first study examining effects of co-occurring risk factors on arrest in a large population with opioid dependency/abuse. These findings identify predictors of arrest that could be used to design interventions targeting specific co-occurring risk factors.
Introduction to journal issue about the 2014 Clinical Prevention and Population Health Curriculum Framework.
BACKGROUND: Buprenorphine is the most frequently prescribed medication for treating substance use disorders in the United States, but few studies have evaluated the structure of treatment delivered in real-world settings. The purpose of this study is to investigate adherence to current buprenorphine treatment guidelines using administrative data for Massachusetts Medicaid.
METHODS: We identified buprenorphine treatment episodes beginning in 2009 through pharmacy claims. We then used service claims to identify treatment-related physician, behavioral, and laboratory services received in the induction, stabilization, and maintenance phases of these treatment episodes. Rates of service utilization were compared with those recommended in treatment guidelines.
RESULTS: A total of 3674 treatment episodes met inclusion criteria, representing 3005 unique Medicaid beneficiaries. Liver enzymes were tested in 47.3% of episodes, but testing for hepatitis C (23.2%), hepatitis B (19.6%), and human immunodeficiency virus (HIV; 13.7%) was less frequent. Adherence to recommended physician visit frequency was 37.6% during induction, 39.7% during stabilization, and 51.2% during maintenance. For behavioral care, adherence rates were 40.0% during induction, 41.2% during stabilization, and 41.0% during maintenance. Rates of toxicology testing met or exceeded recommendations in just over 60% of episodes in the induction (61.1%), stabilization (62.1%), and maintenance (61.4%) phases. Although rates varied by treatment phase, substantial proportions of episodes showed no evidence of physician visits (27.2-42.8%), behavioral care (44.3-60.0%), and toxicology screening (25.3-39.0%).
CONCLUSIONS: Our data suggest that there is significant variability in the structure of buprenorphine treatment provided to Massachusetts Medicaid beneficiaries, and that half or less of episodes include physician and behavioral visits at recommended frequencies. The use of administrative data for this type of analysis is limited by the potential for missing or inaccurate data. More research is needed to establish the levels of services most closely associated with positive outcomes to help guide providers in offering the highest-quality care.
BACKGROUND: Healthy, productive employees are an integral part of school health programs. There have been few assessments of work productivity among secondary school staff. This study describes the frequency of 3 common health risk factors--obesity, depressive symptoms, and smoking--and their impact on work productivity in secondary school employees.
METHODS: Employees of secondary schools in Massachusetts (N = 630) participated in a longitudinal weight gain prevention intervention study. Assessment completed at baseline, 1-year and 2-year follow-up included survey assessments of health risk factors as well as measurements for height, weight, and body mass index (BMI). The survey also included a depression inventory and Work Limitations Questionnaire. Data analysis included multivariate mixed effect models to identify productivity differences in relation to BMI, depressive symptoms, and smoking in this population stratified by position type (teacher and other school staff).
RESULTS: The sample included 361 teachers and 269 other school staff. Obesity, depressive symptoms, and smoking were significantly associated with work productivity, including workdays missed because of health concerns (absenteeism) and decreases in on-the-job productivity because of health concerns (presenteeism).
CONCLUSIONS: Three common health conditions, namely obesity, depressive symptoms, and smoking, adversely affect the productivity of high school employees.
The majority of adults in the US living with mental illnesses are parents. However, service providers often express concern that they are not prepared to work with clients who are parents, feeling they lack the necessary tools and skills to identify and meet their needs. Let’s Talk About Parenting (LTP) supports providers to explore the experiences and impact of parenthood and family life on adult clients and to identify their goals and needs, keeping parenthood and family life in mind. LT-RP is an adaptation of the Finnish Let’s Talk model, an evidence-based psychosocial intervention to assist adult clients/parents with mental illness to identify and meet the needs of their children.
House Librarians as Instructors in a Self-Directed, Capstone-Related 3rd Year Flexible Clinical Experience Program
In academic year 2010/2011, the University of Massachusetts Medical School introduced a new, longitudinal, integrative curriculum (LiNC). One component of this new curriculum was the introduction of Learning Communities or "Houses.". Five Houses were formed to allow inter-class interaction, each that would serve as the medical student's academic and social home. A librarian from the Lamar Soutter Library was attached to each House. Two new components of the LiNC curriculum were a) a longitudinal, cumulative capstone project and b) a 3rd year Flexible Clinical Experience (FCE) program. The first was a natural fit for the House Librarians to interact with students as they conducted foundational research for their Capstone. The second was developed to allow students in their 3rd year an opportunity to choose a pre-designed elective or design their own clinical experience. One type of self-designed FCE is based in the library where students can spend one week conducting research towards their capstone project.
Beginning in academic year 2015/2016, students choosing the library-based FCE are formally required to work with their House Librarian. The librarians now act as the course supervisors. The students share their capstone proposals with their House Librarian and the librarians, in turn, provide comprehensive, library-based research experience, guide students to relevant resources, teach search techniques, and serve as library support for any library or research needs. Following each FCE, the students submit course evaluations. By the spring of 2016, there will be a significant number of evaluations from students that have completed the self-directed FCE with librarian supervision. The authors plan to review the FCE library-based course evaluations for the current year against those from when the House Librarians were not directly involved.
The capstone project can take many different forms, from a traditional research paper to a community outreach project to an artistic expression of medical education. But regardless of format, the capstone must consist of a scientific foundation, guided by evidence and grounded in a fundamental understanding of the literature. By comparing student evaluations responses from before and after formal librarian involvement, we hope to understand the impact librarians have had on capstone preparation, further adapt our methods to improve library integration into this component of the curriculum and explore ways to encourage more students to select the library-based FCE.
Because the library-based FCE now requires students to have direct supervision by their House Librarians, our goal is to use information gleaned from the student evaluations to learn how librarian immersion in this component of the curriculum can contribute to the success of both the self-designed FCE and capstone projects.
The Development of a Standardized Tool to Evaluate Physical Health Websites through the Lens of Persons with Serious Mental Illness
In 2015, the Lamar Soutter Library and the Department of Psychiatry at the University of Massachusetts Medical School received a grant from the National Library of Medicine to design an online tool that will provide persons with serious mental illness a means to acquire resources that will assist them in learning about co-morbidities often faced by this population. One of the first steps in creating this tool is to identify health-related websites that will meet strict quality measures applicable for use by our target audience. To facilitate this process, subject experts with skills in both mental health and physical health have been identified and will be asked to complete a comprehensive survey that will evaluate the identified websites. The survey will address aspects of each website reviewed such as content and credibility, format, usability and interactivity plus the evaluation of etiologic, diagnostic, therapeutic and/or prognostic information contained on the site. This poster will describe the evidence-based methodology used in developing and testing this survey instrument. Preliminary results, discussion of evaluative data and next steps will also be discussed.
Objective: To evaluate prehabilitation exercises to improve shoulder pain and abduction range of motion (ROM) after breast cancer surgery; to evaluate methods of exercise teaching; to assess postsurgical seroma formation.
Design: Pilot study
Setting: Academic medical center
Participants: 60 breast cancer patients were randomly assigned to either personal exercise instruction, group 1, n=36, or video only instruction, group 2, n=24.
Interventions: Shoulder exercises were assigned to both groups 1 month prior to surgery at an outpatient visit. Group 1 received personal instruction on exercises, plus written exercise instruction, and a link to access an online video. Group 2 received only written exercise instruction and a link to access the online video.
Main Outcome Measures: Exercise compliance, pain (via visual analog scale), shoulder abduction ROM (via goniometer), and presence or absence of seroma.
Results or Clinical Course: 76% of study patients chose to exercise. There was no difference in exercise compliance between personal instruction versus video teaching. (75%, 24/32 in-person vs. 77%, 10/13 video only, OR=1.03). 66% of patients (20/30) lost greater than 10 degrees shoulder abduction ROM at 1 month post surgery. 29% of patients (9/31) had worse shoulder pain at one month post surgery than at baseline (24%, 6/25 exercisers, and 50%, 3/6 non-exercisers). 15% of patients (4/27) had worse shoulder pain at 3 months post surgery than at baseline (8%, 2/25 exercisers, and 100%, 2/2 non-exercisers). Prehabilitation exercise program inferred no additional risk of seroma formation (21%, 7/33 exercisers vs. 22%, 2/9 non-exercisers OR=.94).
Conclusion: In-person teaching does not appear superior to video teaching for prehabilitation exercises in breast cancer. A high quality randomized controlled trial is necessary to assess efficacy of prehabilitation for improving post surgical outcomes. Prehabilitation exercises do not appear to increase risk of seroma formation in breast cancer surgery.
Case Diagnosis: On intake exam, patient reported twenty year history of shoulder pain and history of bilateral subacromial bursitis . On the day of the exam, she rated her left shoulder pain (ipsilateral to breast cancer) at 2/10. Physical exam showed tenderness over left subacromial bursa, pain with resisted shoulder abduction and external rotation and ROM limited 120 degrees or less bilaterally.
Case Description: Here, we report the case of a 73 year old woman with a 20 year history of bilateral subacromial bursitis and left shoulder pain who began an independent daily shoulder exercise regimen as instructed by a physiatrist 2.5 weeks prior to left sided lumpectomy for breast cancer, and continued the exercises following the operation. One month post-surgery, physical exam revealed no loss in range of motion (ROM) in flexion and abduction of the left and right shoulders. Patient reported intermittent pain, manageable with NSAIDs, which started only after tamoxifen use.
Discussion: Decline in physical functioning such as loss of ROM, decreased strength, and pain following surgery for breast cancer is a well-documented phenomenon associated with difficulties in performing activities of daily living (ADL). Studies have shown that rehabilitation interventions during treatment period following breast cancer surgery result in improvements in shoulder and arm function; however, no study to date investigated the effectiveness of interventions initiated before surgery (prehabilitation) for breast cancer.
Conclusions: A daily exercise regimen prior to and following lumpectomy for breast cancer may prevent the development of shoulder dysfunction that is often reported in the cancer treatment period.
Health literacy-listening skill and patient questions following cancer prevention and screening discussions
OBJECTIVE: Patient question-asking is essential to shared decision making. We sought to describe patients' questions when faced with cancer prevention and screening decisions, and to explore differences in question-asking as a function of health literacy with respect to spoken information (health literacy-listening).
METHODS: Four-hundred and thirty-three (433) adults listened to simulated physician-patient interactions discussing (i) prophylactic tamoxifen for breast cancer prevention, (ii) PSA testing for prostate cancer and (iii) colorectal cancer screening, and identified questions they would have. Health literacy-listening was assessed using the Cancer Message Literacy Test-Listening (CMLT-Listening). Two authors developed a coding scheme, which was applied to all questions. Analyses examined whether participants scoring above or below the median on the CMLT-Listening asked a similar variety of questions.
RESULTS: Questions were coded into six major function categories: risks/benefits, procedure details, personalizing information, additional information, decision making and credibility. Participants who scored higher on the CMLT-Listening asked a greater variety of risks/benefits questions; those who scored lower asked a greater variety of questions seeking to personalize information. This difference persisted after adjusting for education.
CONCLUSION: Patients' health literacy-listening is associated with distinctive patterns of question utilization following cancer screening and prevention counselling. Providers should not only be responsive to the question functions the patient favours, but also seek to ensure that the patient is exposed to the full range of information needed for shared decision making.
AIMS: High body mass index (BMI) is a risk factor for atrial fibrillation (AF). The aim of this study was to determine whether lean body mass (LBM) predicts AF.
METHODS AND RESULTS: The Women's Health Initiative is a study of post-menopausal women aged 50-79 enrolled at 40 US centres from 1994 to 1998. A subset of 11 393 participants at three centres underwent dual-energy X-ray absorptiometry. Baseline demographics and clinical histories were recorded. Incident AF was identified using hospitalization records and diagnostic codes from Medicare claims. A multivariable Cox hazard regression model adjusted for demographic and clinical risk factors was used to evaluate associations between components of body composition and AF risk. After exclusion for prevalent AF or incomplete data, 8832 participants with an average age of 63.3 years remained for analysis. Over the 11.6 years of average follow-up time, 1035 women developed incident AF. After covariate adjustment, all measures of LBM were independently associated with higher rates of AF: total LBM [hazard ratio (HR) 1.24 per 5 kg increase, 95% confidence intervals (CI) 1.14-1.34], central LBM (HR 1.51 per 5 kg increase, 95% CI 1.31-1.74), and peripheral LBM (HR 1.39 per 5 kg increase, 95% CI 1.19-1.63). The association between total LBM and AF remained significant after adjustment for total fat mass (HR 1.22 per 5 kg increase, 95% CI 1.13-1.31).
CONCLUSION: Greater LBM is a strong independent risk factor for AF. After adjusting for obesity-related risk factors, the risk of AF conferred by higher BMI is primarily driven by the association between LBM and AF.
HLA Class I Supertype Associations With Clinical Outcome of Secondary Dengue Virus Infections in Ethnic Thais
BACKGROUND: Human leukocyte antigen (HLA) supertypes are groups of functionally related alleles that present structurally similar antigens to the immune system.
OBJECTIVES: To analyze HLA class I supertype associations with clinical outcome in hospitalized Thai children with acute dengue illness.
METHODS: Seven hundred sixty-two patients and population-matched controls recruited predominantly in Bangkok were HLA-A and -B typed. HLA supertype frequencies were compared and tested for significant dengue disease associations using logistic regression analyses. Multivariable models were built by conducting forward stepwise selection procedures.
RESULTS: In the final logistic regression model, the HLA-B44 supertype was protective against dengue hemorrhagic fever (DHF) in secondary infections (odds ratio [OR] = 0.46, 95% confidence interval [CI], .30-.72), while the HLA-A02 supertype (OR = 1.92, 95% CI, 1.30-2.83) and the HLA-A01/03 supertype (OR = 3.01, 95% CI, 1.01-8.92) were associated with susceptibility to secondary dengue fever. The B07 supertype was associated with susceptibility to secondary DHF in the univariate analysis (OR = 1.60, 95% CI, 1.05-2.46), whereas that was not retained in the final model.
CONCLUSIONS: As the HLA-B44 supertype is predicted to target conserved epitopes in dengue, our results suggest that B44 supertype-restricted immune responses to highly conserved regions of the dengue proteome may protect against secondary DHF.
Endoplasmic Reticulum Stress Activates the Inflammasome via NLRP3- and Caspase-2-Driven Mitochondrial Damage
Endoplasmic reticulum (ER) stress is observed in many human diseases, often associated with inflammation. ER stress can trigger inflammation through nucleotide-binding domain and leucine-rich repeat containing (NLRP3) inflammasome, which might stimulate inflammasome formation by association with damaged mitochondria. How ER stress triggers mitochondrial dysfunction and inflammasome activation is ill defined. Here we have used an infection model to show that the IRE1alpha ER stress sensor regulates regulated mitochondrial dysfunction through an NLRP3-mediated feed-forward loop, independently of ASC. IRE1alpha activation increased mitochondrial reactive oxygen species, promoting NLRP3 association with mitochondria. NLRP3 was required for ER stress-induced cleavage of caspase-2 and the pro-apoptotic factor, Bid, leading to subsequent release of mitochondrial contents. Caspase-2 and Bid were necessary for activation of the canonical inflammasome by infection-associated or general ER stress. These data identify an NLRP3-caspase-2-dependent mechanism that relays ER stress to the mitochondria to promote inflammation, integrating cellular stress and innate immunity.
Low-Fat Dietary Pattern Intervention and Health-Related Quality of Life: The Women's Health Initiative Randomized Controlled Dietary Modification Trial
BACKGROUND: Intensive dietary intervention programs may lead to benefits in vitality and other components of health quality. The Women's Health Initiative Dietary Modification (DM) intervention includes a large randomized controlled trial of an intensive intervention.
OBJECTIVE: To evaluate whether the intervention is associated with improved health-related quality of life (HRQoL) subscales, overall self-reported health, depression symptoms, cognitive functioning, and sleep quality.
DESIGN: This randomized controlled trial was analyzed as intent to treat.
PARTICIPANTS: Between 1993 and 1998, 48,835 women aged 50 to 79 years were recruited by 40 clinical centers across the United States. Eligibility included having fat intake at baseline > /=32% of total calories, and excluded women with any prior colorectal or breast cancer, recent other cancers, type 1 diabetes, or medical conditions with predicted survival < 3 years.
INTERVENTION: Goals were to reduce calories from fat to 20%, increase vegetables and fruit to 5+ servings, and increase grain servings to 6+ servings a day. During the first year, 18 group sessions were held, with quarterly sessions thereafter.
MAIN OUTCOME MEASURES: The RAND 36-Item Health Survey was used to assess HRQoL at baseline, Year 1, and close-out (about 8 years postrandomization), and estimate differential HRQoL subscale change scores.
STATISTICAL ANALYSES PERFORMED: Mean change in HRQoL scores (Year 1 minus baseline) were compared by randomization group using linear models.
RESULTS: At 1 year, there was a differential change between intervention and comparison group of 1.7 units (95% CI 1.5, 2.0) in general health associated with the intervention. DM intervention improved physical functioning by 2.0 units (95% CI 1.7, 2.3), vitality by 1.9 units (95% CI 1.6, 2.2), and global quality of life by 0.09 units (95% CI 0.07, 0.12). With the exception of global quality of life, these effects were significantly modified by body mass index at baseline.
CONCLUSIONS: DM intervention was associated with small, but significant improvements in three HRQoL subscales: general health, physical functioning, and vitality at 1 year follow-up, with the largest improvements seen in the women with the greatest baseline body mass index.