Positive psychological interventions for improving health have received increasing attention rece... more Positive psychological interventions for improving health have received increasing attention recently. Evidence on the impact of such interventions on pain, and racial disparities in pain, is limited. OBJECTIVE To assess the effects of a positive psychological intervention on pain and functional difficulty in veterans with knee osteoarthritis. DESIGN, SETTING, AND PARTICIPANTS The Staying Positive With Arthritis Study is a large, doubleblinded randomized clinical trial powered to detect race differences in self-reported pain in response to a positive psychological intervention compared with a neutral control intervention. Data were collected from 2 urban Veterans Affairs medical centers. Participants included non-Hispanic white and non-Hispanic African American patients aged 50 years or older with a diagnosis of osteoarthritis. Mailings were sent to 5111 patients meeting these criteria, of whom 839 were fully screened, 488
Racial and ethnic health disparities are a national health issue. They are well described in othe... more Racial and ethnic health disparities are a national health issue. They are well described in other chronic diseases, but in rheumatoid arthritis (RA), research into their causes, outcomes, and elimination is in its early stages. Health disparities occur in a complex milieu, with systemlevel, provider-level, and individual-level factors playing roles. Dissecting the overlapping aspects of race/ethnicity, socioeconomic variables, and how their individual components combine to explain the magnitude of disparities in RA can be challenging. Recent research has focused on the extent to which treatment preferences, adherence, trust in physicians, patient-physician communication, health literacy, and depression have contributed to observed disparities in RA. Practicing evidence-based medicine, improving patient-physician communication skills, reducing language and literacy barriers, improving adherence to therapies, raising awareness of racial/ethnic disparities, and recognizing comorbidities such as depression are steps clinicians may take to help eliminate racial/ethnic disparities in RA.
ABSTRACT Background Elective TKR is an effective treatment option for end-stage knee osteoarthrit... more ABSTRACT Background Elective TKR is an effective treatment option for end-stage knee osteoarthritis (OA) that is rapidly growing. Although women have as much or greater prevalence of knee OA than men, men undergo TKR more often than women. Patient preference is emerging as an important consideration in TKR gender disparities. However, few studies have examined the determinants of patients’ preference in a racially diverse sample of men and women. Objectives We sought to identify whether determinants of patients’ preference for TKR differ by gender. Methods Our sample consisted of 509 women (59% white) and 290 men (73% white) with chronic, frequent knee pain and radiographic evidence of knee OA. We used logistic regression models, stratified by gender, to identify clinical and socio-cultural determinants of patients’ preference for TKR. Clinical and socio-cultural factors were entered simultaneously into the stratified models. Stepwise selection methods were used to select socio-cultural items to be included in the final models, using a criterion of p<0.20. All models were adjusted for age, income level, disease severity (using the WOMAC), and study site. Results White women had lower preference for TKR compared to white men (adjusted OR=0.56, 95%CI 0.34 to 0.94), whereas African-American (AA) women had higher preference for TKR compared to AA men (adjusted OR=1.24, 95%CI 0.70 to 2.18). Among women, items related to knowledge (p<0.001) and expectations (p=0.007) regarding surgical outcomes, and religiosity (p=0.045) were selected for inclusion in the multivariate model. Among men, items related to knowledge (p=0.46) and expectations regarding surgical outcomes (p=0.027) were selected for inclusion in the multivariate model (see Table 1). Conclusions Expectations regarding surgical outcomes are important for both men and women with regard to their preferences for TKR, but the genders differ with regard to which other socio-cultural determinants impact these preferences. Interventions to reduce or eliminate gender disparities in the utilization of TKR should consider and target these factors. Disclosure of Interest None Declared
The Centers for Medicare & Medicaid Services (CMS)/Premier Hospital Quality Incentive Demonstrati... more The Centers for Medicare & Medicaid Services (CMS)/Premier Hospital Quality Incentive Demonstration (HQID) project aims to improve clinical performance through a pay-for-performance program. We conducted this study to identify the key organizational factors associated with higher performance. METHODS: An investigator-blinded, structured telephone survey of eligible hospitals' (N=92) quality improvement (QI) leaders was conducted among HQID hospitals in the top 2 or bottom 2 deciles submitting performance measure data from October 2004 to September 2005. The survey covered topics such as QI interventions, data feedback, physician leadership, support for QI efforts, and organizational culture. RESULTS: More top performing hospitals used clinical pathways for the treatment of AMI (49% vs. 15%, p< 0.01), HF (44% vs. 18%, p<0.01), PN (38% vs. 13%, p< 0.01) and THR/TKR (56% vs. 23%, p<0.01); organized into multidisciplinary teams to manage patients with AMI (93% vs. 77%, p<0.05) and HF (93% vs. 69%, p< 0.01); used order sets for the treatment of THR/TKR (91% vs. 64%, p<0.01); and implemented computerized physician order entry in the hospital (24.4% vs. 7.9%, p<0.05). Finally, more top performers reported having adequate human resources for QI projects (p<0.01); support of the nursing staff to increase adherence to quality indicators (p < 0.01); and an organizational culture that supported coordination of care (p<0.01), pace of change (p<0.01), willingness to try new projects (p <0.01), and a focus on identifying system errors rather than blaming individuals (p<0.05). CONCLUSIONS: Organizational structure, support, and culture are associated with high performance among hospitals participating in a pay-for-performance demonstration project. Multiple organizational factors remain important in optimizing clinical care.
ObjectiveThis study sought to determine the extent to which physical activity confounds the relat... more ObjectiveThis study sought to determine the extent to which physical activity confounds the relation between race and the incidence of osteoarthritis (OA)‐related functional limitation.MethodsOA Initiative study participants with or at increased risk of knee OA who wore an accelerometer were included. Race was self‐reported. Average time spent in moderate to vigorous physical activity (minutes per day) based on ActiGraph uniaxial accelerometer data was assessed. Functional limitation was based on the following: (1) inability to achieve a community walking speed (1.2 m/s) standard, (2) slow walking speed (<1.0 m/s), and (3) low physical functioning based on a Western Ontario and McMaster Universities OA Index (WOMAC) physical function score greater than 28 of 68.ResultsAfrican American (AA) participants (n = 226), compared with White participants (n = 1348), had a higher likelihood of developing functional limitation based on various measures. When adjusted for time in moderate to...
The objective of this study was to evaluate how patient knowledge and beliefs regarding nonsteroi... more The objective of this study was to evaluate how patient knowledge and beliefs regarding nonsteroidal anti‐inflammatory drugs (NSAIDs) may influence the use of NSAIDs for osteoarthritis (OA).
Background: Racial and ethnic disparities in osteoarthritis (OA) patients’ disease experience may... more Background: Racial and ethnic disparities in osteoarthritis (OA) patients’ disease experience may be related to marked differences in the utilization and prescription of pharmacologic treatments. Objectives: The main objective of this rapid systematic review was to evaluate studies that examined race/ethnic differences in the use of pharmacologic treatments for OA. Data sources and methods: A literature search (PubMed and Embase) was ran on 25 February 2022. Studies that evaluated race/ethnic differences in the use of OA pharmacologic treatments were included. Two reviewers independently screened titles and abstracts and abstracted data from full-text articles. Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Results: The search yielded 3880 titles, and 17 studies were included in this review. African Americans and Hispanics were more likely than non-Hispanic Whites to use prescription non-selective non-steroidal anti-inflammatory ...
To identify clinical characteristics, laboratory features, approaches to management, and predicto... more To identify clinical characteristics, laboratory features, approaches to management, and predictors of outcome of chronic inflammatory demyelinating polyneuropathy (CIDP) in patients with systemic lupus erythematosus (SLE). An analysis of 6 adults with the concurrent diagnosis of CIDP and SLE seen at a SLE Clinic from 1994 to 2004 with a review of 13 patients with SLE and CIDP reported in the medical literature from 1950 through 2004. Among our 6 patients with SLE and CIDP, 3 (50%) achieved a substantial clinical response to intravenous immunoglobulin (IVIg) and the remainder had a minimal response. The improved patients were more likely to have received treatment earlier (within 1 year of CIDP onset) and to respond faster (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1 to 3 months) than minimally improved patients. They tended to have CIDP features of weakness of all extremities, hyporeflexia of the upper extremities, and slowed nerve conduction velocity of the motor median nerve. Compared with minimal responders, responders had more serious internal organ manifestations and multiple autoantibodies associated with SLE. Review of the literature identified 13 previously reported CIDP patients with SLE. Many had neurological involvement of all extremities, nerve biopsies showing demyelination, and serious SLE internal organ manifestations. Most were treated with steroids, but the 1 treated with IVIg had similar characteristics to our subset of patients who improved with IVIg. CIDP is an uncommon, but not rare, manifestation of SLE. Certain characteristics including early CIDP diagnosis, involvement of all 4 extremities, hyporeflexia of the upper extremities, and slowed motor nerve conduction velocity of the median nerve in addition to SLE involvement of critical internal organs and the presence of multiple antibodies associated with SLE all appear to predict a good response to IVIg.
Gout, a crystalline arthropathy caused by the deposition of monosodium urate crystals in the arti... more Gout, a crystalline arthropathy caused by the deposition of monosodium urate crystals in the articular and periarticular soft tissues, is a frequent cause of painful arthropathy. Imaging has an important role in the initial evaluation as well as the treatment and follow up of gouty arthropathy. The imaging findings of gouty arthropathy on radiography, ultrasonography, computed tomography, dual energy computed tomography, and magnetic resonance imaging are described to include findings of the early, acute and chronic phases of gout. These findings include early monosodium urate deposits, osseous erosions, and tophi, which may involve periarticular tissues, tendons, and bursae. Treatment of gout includes non-steroidal anti-inflammatories, colchicine, glucocorticoids, interleukin-1 inhibitors, xanthine oxidase inhibitors, uricosuric drugs, and recombinant uricase. Imaging is critical in monitoring response to therapy; clinical management can be modulated based on imaging findings. This...
Nitric oxide (NO) donors are heterogeneous substances which release NO, a biologically active com... more Nitric oxide (NO) donors are heterogeneous substances which release NO, a biologically active compound. NO released by nitric oxide donors has important effects on the circulation by causing vasodilation, diminishing myocardial contractile force, inhibiting platelet aggregation, and counteracting the effects of thromboxane A2. In the infarcted heart, activation of the inducible form of nitric oxide synthase (iNOS) and the formation of prostacyclin and thromboxane A2 by cyclooxygenase (COX) were increased. Myocardial infarction also resulted in increased myocardial NO production. Aspirin (acetylsalicylic acid. ASA) at low concentration (35 mg/kg/day) fails to change iNOS production, in contrast to higher dose (150 mg/kg/day) which, as previously shown, inhibits iNOS activity. ASA at all doses also suppresses myocardial prostanoid formation because of inhibition of COX. Recently, two NO donors have been synthesized: NCX 4016 and Diethylenetriamine/NO (DETA/NO). NCX 4016 combines an NO-releasing moiety with a carboxylic residue via an esteric bond. We describe here that NCX 4016 (65 mg/kg/day) increased prostacyclin and thromboxane A2 production in the infarcted heart muscle, overcoming the inhibitory effects of ASA. As a result of nitric oxide release, oxidation products of NO (NO2- and NO3-; NOx) in arterial blood rose following administration of NCX 4016. On oral administration, NCX 4016 did not change systemic arterial pressure. The effects of a single NO donor, DETA/NO (1.0 mg/kg/day) on the infarcted heart were also investigated On intravenous administration, the compound increased NO concentration in arterial blood slightly but to a lesser degree than NCX 4016. Like NCX 4016, it raised myocardial production of prostacyclin and thromboxane A2 in the infarcted heart. However, it caused a severe fall in blood pressure. These findings demonstrate that newly-synthesized NO donors release nitric oxide in situ and increase myocardial production of prostanoids. NCX 4016 has therapeutic potential because it can be orally administered, lacks hypotensive effects, increases blood levels of nitric oxide and myocardial prostacyclin production.
Systemic lupus erythematosus (SLE) is a complex autoimmune disease that is associated with poor h... more Systemic lupus erythematosus (SLE) is a complex autoimmune disease that is associated with poor health-related quality-of-life outcomes. The objectives of this study were to identify correlates of the domains of the Medical Outcomes Study (MOS) Sleep Scale in SLE and to determine the factors most associated with overall sleep quality. Sleep in 118 SLE patients was assessed using the self-administered MOS Sleep Scale. Bivariate correlations were determined between each of 6 MOS Sleep subscale scores and each sociodemographic, clinical, or psychological predictor variable. Serial hierarchical multiple regression analyses were computed to identify the variables associated with the individual sleep domains and the overall Sleep Problems Index. The MOS Sleep Scale scores of patients with SLE were poorer than the US general population. Depression moderately correlated with 5 (all P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01) and anxiety with 4 subscale scores (all P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). The SLE Disease Activity Index did not significantly correlate with any of the subscale scores. Results of a multivariate regression model showed that sleep adequacy and sleep disturbance were independently associated with depression (β = -0.84; 95% confidence interval [CI], -1.37 to -0.32; and β = 0.80; 95% CI, 0.15-1.45; respectively). Daytime somnolence was significantly associated with daily prednisone dosage (β = 0.54; 95% CI, 0.29-0.80) and anxiety trait (β = 0.81; 95% CI, 0.41-1.21). Snoring independently correlated with anxiety (β = 1.64; 95% CI, 0.80-2.29). When demographic, clinical, and psychological variables were simultaneously regressed on the Sleep Problems Index, pain trended toward association with overall sleep problems (β = 0.17; 95% CI, -0.02 to 0.36). Patients with SLE have greater sleep problems relative to the general population. Psychosocial factors, particularly depression and anxiety, are important determinants that are significantly associated with sleep abnormalities in SLE.
The American Journal of Tropical Medicine and Hygiene, 2010
West Nile virus (WNV) was introduced into North America in 1999 and has now become endemic in the... more West Nile virus (WNV) was introduced into North America in 1999 and has now become endemic in the United States with outbreaks each summer and fall. The virus initially spread throughout the eastern parts of the United States and gradually moved westward. In 2008, human WNV cases were reported in 45 states. Most human WNV infections are asymptomatic. 3 Among persons with clinical illness, the features of acute illness range from uncomplicated West Nile fever to neuroinvasive conditions such as meningitis, encephalitis, and acute flaccid paralysis. After acute illness, many persons recover to their previous state of health. However, 20-50% of persons with clinically diagnosed WNV infection report persistent sequelae including somatic symptoms, cognitive and memory problems, depression, and balance and mobility difficulties. Conclusions regarding the duration of such symptoms have been somewhat inconsistent, with several studies reporting persistent symptoms at 6 and 12 months after the acute infection, 4-6, 8, 10, 12, 13 whereas a recent study concluded that nearly all persons with WNV will recover full function within one year after infection. The reasons for variation in clinical outcomes remain relatively unknown. Previous studies suggest that older age, neuroinvasive disease, medical comorbidities, and more recent infection are associated with more clinically severe outcomes. In many of these studies, the clinical outcome was limited to one or two specific signs and symptoms (e.g., neurologic dysfunction, memory test, presence of specific symptom). Our study objectives were to determine the prevalence of long-term symptoms among persons diagnosed with WNV during 2006-2008 and to determine the association of age, sex, neuroinvasive disease status, hypertension or diabetes, and time since acute infection on the most common individual symptoms. Participants were recruited from persons with WNV who were reported to two of the seven district health departments in Idaho during 2006-2008. All persons were classified as having either confirmed (95%) or probable (5%) WNV infections according to standard case definitions that include a positive IgM test result for WNV and a compatible clinical syndrome. In 2006, Idaho had the greatest number of WNV infections in the United States, and the state continued to be among the top 10 in terms of total reported cases in 2007-2008. As part of a larger study designed to study the immunology of WNV infection, health department staff mailed questionnaires to 407 persons with a newly reported diagnosis of WNV infection; 280 persons returned them (response = 69%). We excluded 3 persons whose surveys included more than 50% missing data, and 12 persons who were asymptomatic at baseline diagnosis. Compared with all persons with WNV who were reported to the two district health departments during this period, the survey respondents were slightly more likely to be female (60% versus 51%), but similar in terms of the proportion with neuroinvasive disease (21% versus 21%). All study procedures were approved by institutional review boards at participating universities and the two local health departments. The questionnaires included items that assessed demographic characteristics, presence of diabetes or hypertension, initial severity of illness (e.g., hospitalization), and impact on work. Time since acute infection was calculated as the number of days from the date of disease onset (self-report) to the date that the questionnaire was completed and rounded to the nearest month. Collaborators at the district health departments provided information on neuroinvasive disease status based on epidemiologic investigation and defined according to standardized case definitions. 2 Symptom Measures. The questionnaire assessed 17 promi nent symptoms that have been associated with WNV infection. Specifically, persons were asked to report if they "had any of the following symptoms with your West Nile virus infection". For each symptom reported, persons were asked to "indicate how severe the symptom was (options low/mild, medium, or severe), and "how long did the symptom last", (options = 1-2 days,
Objectives-Characterize radiographic worsening in knee osteoarthritis (KOA) by race and sex over ... more Objectives-Characterize radiographic worsening in knee osteoarthritis (KOA) by race and sex over four years and evaluate the role of established risk factors in observed race/sex differences Methods-Whites (WHs) (694 males, 929 females) and African-Americans (AAs) (92 males, 167 females) at risk for radiographic KOA were eligible. Cox shared frailty models were used to estimate race and sex group differences in radiographic worsening, defined by Kellgren-Lawrence (K-L) and OARSI joint space narrowing (JSN). Mixed effect models for repeated measures were used to estimate race-and sex-specific mean medial and lateral fixed joint space width (fJSW) over four years of follow-up, as well as annual loss of fJSW. Results-Risk of OARSI medial JSN grade worsening was higher among AA males than WH females (HR 2.28, [95% CI: 1.14-4.57]), though adjustment for KOA risk factors attenuated the association. Compared to WH females, WH males had lower risk of K-L grade worsening (adjusted HR 0.75 [95% CI: 0.58-0.96]). Mean baseline medial fJSW (mm) was 6.49 in WH and AA males, 5.42 in WH females, and 5.41 in AA females. Annual change in mean medial fJSW was greater in AA males (-0.19 mm/year) than in other subgroups (-0.09 WH males, -0.07 WH females, -0.10 AA females, p<0.0001). Compared to WHs, AAs had less lateral fJSW at baseline and throughout follow-up. Conclusions-Compared to WHs and AA females, AA males experienced higher risk of medial joint space loss. Controlling for established risk factors attenuated associations between race/sex and disease worsening, suggesting that risk factors such as obesity, history of knee injury, and bony finger joint enlargements largely explain race/sex variations in rates of KOA development and progression.
Knowledge, attitudes and beliefs of White OA patients by willingness to undergo TKR Surgery. (DOC... more Knowledge, attitudes and beliefs of White OA patients by willingness to undergo TKR Surgery. (DOCX 25 kb)
Knowledge, attitudes and beliefs of African-American OA patients by willingness to undergo TKR Su... more Knowledge, attitudes and beliefs of African-American OA patients by willingness to undergo TKR Surgery. (DOCX 25 kb)
ObjectiveWhile opioids are known to cause unintended adverse effects, they are being utilized by ... more ObjectiveWhile opioids are known to cause unintended adverse effects, they are being utilized by a number of patients with osteoarthritis (OA). The aim of this study was to evaluate the association of patient familiarity and perceptions regarding efficacy and risks with opioid medication use for OA.MethodsA total of 362 adults with knee and/or hip OA were surveyed in this cross-sectional study. Patients’ familiarity with and perceptions of benefits/risks of opioid medications were measured to evaluate potential associations with the utilization of opioid medications for OA within the last 6 months. Logistic regression models were adjusted for sociodemographic and clinical variables.ResultsIn this sample, 28.7% (100/349) reported use of an opioid medication for OA-related symptoms in the last 6 months. Those who were on an opioid medication, compared to those who were not, were younger (mean age 62.5 vs 64.8 yrs), were more likely to have a high school education or lower (48.0% vs 35...
To evaluate race and gender variations in complementary and alternative medicine (CAM) use for kn... more To evaluate race and gender variations in complementary and alternative medicine (CAM) use for knee osteoarthritis (OA) (unadjusted and adjusted for demographic and clinical factors).
ObjectivePerceived discrimination is associated with chronic pain and depression and contributes ... more ObjectivePerceived discrimination is associated with chronic pain and depression and contributes to racial health disparities. In a cohort of older adult veterans with osteoarthritis (OA), our objective was to examine how membership in multiple socially disadvantaged groups (cumulative disadvantage) was associated with perceived discrimination, pain, and depression. We also tested whether perceived discrimination mediated the association of cumulative disadvantage with depression and pain.MethodsWe analyzed baseline data from 270 African American veterans and 247 White veterans enrolled in a randomized controlled trial testing a psychological intervention for chronic pain at 2 Department of Veterans Affairs medical centers. Participants were age ≥50 years and self‐reported symptomatic knee OA. Measures included the Everyday Discrimination Scale, the Patient Health Questionnaire Depression Scale, the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale, and de...
Positive psychological interventions for improving health have received increasing attention rece... more Positive psychological interventions for improving health have received increasing attention recently. Evidence on the impact of such interventions on pain, and racial disparities in pain, is limited. OBJECTIVE To assess the effects of a positive psychological intervention on pain and functional difficulty in veterans with knee osteoarthritis. DESIGN, SETTING, AND PARTICIPANTS The Staying Positive With Arthritis Study is a large, doubleblinded randomized clinical trial powered to detect race differences in self-reported pain in response to a positive psychological intervention compared with a neutral control intervention. Data were collected from 2 urban Veterans Affairs medical centers. Participants included non-Hispanic white and non-Hispanic African American patients aged 50 years or older with a diagnosis of osteoarthritis. Mailings were sent to 5111 patients meeting these criteria, of whom 839 were fully screened, 488
Racial and ethnic health disparities are a national health issue. They are well described in othe... more Racial and ethnic health disparities are a national health issue. They are well described in other chronic diseases, but in rheumatoid arthritis (RA), research into their causes, outcomes, and elimination is in its early stages. Health disparities occur in a complex milieu, with systemlevel, provider-level, and individual-level factors playing roles. Dissecting the overlapping aspects of race/ethnicity, socioeconomic variables, and how their individual components combine to explain the magnitude of disparities in RA can be challenging. Recent research has focused on the extent to which treatment preferences, adherence, trust in physicians, patient-physician communication, health literacy, and depression have contributed to observed disparities in RA. Practicing evidence-based medicine, improving patient-physician communication skills, reducing language and literacy barriers, improving adherence to therapies, raising awareness of racial/ethnic disparities, and recognizing comorbidities such as depression are steps clinicians may take to help eliminate racial/ethnic disparities in RA.
ABSTRACT Background Elective TKR is an effective treatment option for end-stage knee osteoarthrit... more ABSTRACT Background Elective TKR is an effective treatment option for end-stage knee osteoarthritis (OA) that is rapidly growing. Although women have as much or greater prevalence of knee OA than men, men undergo TKR more often than women. Patient preference is emerging as an important consideration in TKR gender disparities. However, few studies have examined the determinants of patients’ preference in a racially diverse sample of men and women. Objectives We sought to identify whether determinants of patients’ preference for TKR differ by gender. Methods Our sample consisted of 509 women (59% white) and 290 men (73% white) with chronic, frequent knee pain and radiographic evidence of knee OA. We used logistic regression models, stratified by gender, to identify clinical and socio-cultural determinants of patients’ preference for TKR. Clinical and socio-cultural factors were entered simultaneously into the stratified models. Stepwise selection methods were used to select socio-cultural items to be included in the final models, using a criterion of p&lt;0.20. All models were adjusted for age, income level, disease severity (using the WOMAC), and study site. Results White women had lower preference for TKR compared to white men (adjusted OR=0.56, 95%CI 0.34 to 0.94), whereas African-American (AA) women had higher preference for TKR compared to AA men (adjusted OR=1.24, 95%CI 0.70 to 2.18). Among women, items related to knowledge (p&lt;0.001) and expectations (p=0.007) regarding surgical outcomes, and religiosity (p=0.045) were selected for inclusion in the multivariate model. Among men, items related to knowledge (p=0.46) and expectations regarding surgical outcomes (p=0.027) were selected for inclusion in the multivariate model (see Table 1). Conclusions Expectations regarding surgical outcomes are important for both men and women with regard to their preferences for TKR, but the genders differ with regard to which other socio-cultural determinants impact these preferences. Interventions to reduce or eliminate gender disparities in the utilization of TKR should consider and target these factors. Disclosure of Interest None Declared
The Centers for Medicare & Medicaid Services (CMS)/Premier Hospital Quality Incentive Demonstrati... more The Centers for Medicare & Medicaid Services (CMS)/Premier Hospital Quality Incentive Demonstration (HQID) project aims to improve clinical performance through a pay-for-performance program. We conducted this study to identify the key organizational factors associated with higher performance. METHODS: An investigator-blinded, structured telephone survey of eligible hospitals' (N=92) quality improvement (QI) leaders was conducted among HQID hospitals in the top 2 or bottom 2 deciles submitting performance measure data from October 2004 to September 2005. The survey covered topics such as QI interventions, data feedback, physician leadership, support for QI efforts, and organizational culture. RESULTS: More top performing hospitals used clinical pathways for the treatment of AMI (49% vs. 15%, p< 0.01), HF (44% vs. 18%, p<0.01), PN (38% vs. 13%, p< 0.01) and THR/TKR (56% vs. 23%, p<0.01); organized into multidisciplinary teams to manage patients with AMI (93% vs. 77%, p<0.05) and HF (93% vs. 69%, p< 0.01); used order sets for the treatment of THR/TKR (91% vs. 64%, p<0.01); and implemented computerized physician order entry in the hospital (24.4% vs. 7.9%, p<0.05). Finally, more top performers reported having adequate human resources for QI projects (p<0.01); support of the nursing staff to increase adherence to quality indicators (p < 0.01); and an organizational culture that supported coordination of care (p<0.01), pace of change (p<0.01), willingness to try new projects (p <0.01), and a focus on identifying system errors rather than blaming individuals (p<0.05). CONCLUSIONS: Organizational structure, support, and culture are associated with high performance among hospitals participating in a pay-for-performance demonstration project. Multiple organizational factors remain important in optimizing clinical care.
ObjectiveThis study sought to determine the extent to which physical activity confounds the relat... more ObjectiveThis study sought to determine the extent to which physical activity confounds the relation between race and the incidence of osteoarthritis (OA)‐related functional limitation.MethodsOA Initiative study participants with or at increased risk of knee OA who wore an accelerometer were included. Race was self‐reported. Average time spent in moderate to vigorous physical activity (minutes per day) based on ActiGraph uniaxial accelerometer data was assessed. Functional limitation was based on the following: (1) inability to achieve a community walking speed (1.2 m/s) standard, (2) slow walking speed (<1.0 m/s), and (3) low physical functioning based on a Western Ontario and McMaster Universities OA Index (WOMAC) physical function score greater than 28 of 68.ResultsAfrican American (AA) participants (n = 226), compared with White participants (n = 1348), had a higher likelihood of developing functional limitation based on various measures. When adjusted for time in moderate to...
The objective of this study was to evaluate how patient knowledge and beliefs regarding nonsteroi... more The objective of this study was to evaluate how patient knowledge and beliefs regarding nonsteroidal anti‐inflammatory drugs (NSAIDs) may influence the use of NSAIDs for osteoarthritis (OA).
Background: Racial and ethnic disparities in osteoarthritis (OA) patients’ disease experience may... more Background: Racial and ethnic disparities in osteoarthritis (OA) patients’ disease experience may be related to marked differences in the utilization and prescription of pharmacologic treatments. Objectives: The main objective of this rapid systematic review was to evaluate studies that examined race/ethnic differences in the use of pharmacologic treatments for OA. Data sources and methods: A literature search (PubMed and Embase) was ran on 25 February 2022. Studies that evaluated race/ethnic differences in the use of OA pharmacologic treatments were included. Two reviewers independently screened titles and abstracts and abstracted data from full-text articles. Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Results: The search yielded 3880 titles, and 17 studies were included in this review. African Americans and Hispanics were more likely than non-Hispanic Whites to use prescription non-selective non-steroidal anti-inflammatory ...
To identify clinical characteristics, laboratory features, approaches to management, and predicto... more To identify clinical characteristics, laboratory features, approaches to management, and predictors of outcome of chronic inflammatory demyelinating polyneuropathy (CIDP) in patients with systemic lupus erythematosus (SLE). An analysis of 6 adults with the concurrent diagnosis of CIDP and SLE seen at a SLE Clinic from 1994 to 2004 with a review of 13 patients with SLE and CIDP reported in the medical literature from 1950 through 2004. Among our 6 patients with SLE and CIDP, 3 (50%) achieved a substantial clinical response to intravenous immunoglobulin (IVIg) and the remainder had a minimal response. The improved patients were more likely to have received treatment earlier (within 1 year of CIDP onset) and to respond faster (&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;1 to 3 months) than minimally improved patients. They tended to have CIDP features of weakness of all extremities, hyporeflexia of the upper extremities, and slowed nerve conduction velocity of the motor median nerve. Compared with minimal responders, responders had more serious internal organ manifestations and multiple autoantibodies associated with SLE. Review of the literature identified 13 previously reported CIDP patients with SLE. Many had neurological involvement of all extremities, nerve biopsies showing demyelination, and serious SLE internal organ manifestations. Most were treated with steroids, but the 1 treated with IVIg had similar characteristics to our subset of patients who improved with IVIg. CIDP is an uncommon, but not rare, manifestation of SLE. Certain characteristics including early CIDP diagnosis, involvement of all 4 extremities, hyporeflexia of the upper extremities, and slowed motor nerve conduction velocity of the median nerve in addition to SLE involvement of critical internal organs and the presence of multiple antibodies associated with SLE all appear to predict a good response to IVIg.
Gout, a crystalline arthropathy caused by the deposition of monosodium urate crystals in the arti... more Gout, a crystalline arthropathy caused by the deposition of monosodium urate crystals in the articular and periarticular soft tissues, is a frequent cause of painful arthropathy. Imaging has an important role in the initial evaluation as well as the treatment and follow up of gouty arthropathy. The imaging findings of gouty arthropathy on radiography, ultrasonography, computed tomography, dual energy computed tomography, and magnetic resonance imaging are described to include findings of the early, acute and chronic phases of gout. These findings include early monosodium urate deposits, osseous erosions, and tophi, which may involve periarticular tissues, tendons, and bursae. Treatment of gout includes non-steroidal anti-inflammatories, colchicine, glucocorticoids, interleukin-1 inhibitors, xanthine oxidase inhibitors, uricosuric drugs, and recombinant uricase. Imaging is critical in monitoring response to therapy; clinical management can be modulated based on imaging findings. This...
Nitric oxide (NO) donors are heterogeneous substances which release NO, a biologically active com... more Nitric oxide (NO) donors are heterogeneous substances which release NO, a biologically active compound. NO released by nitric oxide donors has important effects on the circulation by causing vasodilation, diminishing myocardial contractile force, inhibiting platelet aggregation, and counteracting the effects of thromboxane A2. In the infarcted heart, activation of the inducible form of nitric oxide synthase (iNOS) and the formation of prostacyclin and thromboxane A2 by cyclooxygenase (COX) were increased. Myocardial infarction also resulted in increased myocardial NO production. Aspirin (acetylsalicylic acid. ASA) at low concentration (35 mg/kg/day) fails to change iNOS production, in contrast to higher dose (150 mg/kg/day) which, as previously shown, inhibits iNOS activity. ASA at all doses also suppresses myocardial prostanoid formation because of inhibition of COX. Recently, two NO donors have been synthesized: NCX 4016 and Diethylenetriamine/NO (DETA/NO). NCX 4016 combines an NO-releasing moiety with a carboxylic residue via an esteric bond. We describe here that NCX 4016 (65 mg/kg/day) increased prostacyclin and thromboxane A2 production in the infarcted heart muscle, overcoming the inhibitory effects of ASA. As a result of nitric oxide release, oxidation products of NO (NO2- and NO3-; NOx) in arterial blood rose following administration of NCX 4016. On oral administration, NCX 4016 did not change systemic arterial pressure. The effects of a single NO donor, DETA/NO (1.0 mg/kg/day) on the infarcted heart were also investigated On intravenous administration, the compound increased NO concentration in arterial blood slightly but to a lesser degree than NCX 4016. Like NCX 4016, it raised myocardial production of prostacyclin and thromboxane A2 in the infarcted heart. However, it caused a severe fall in blood pressure. These findings demonstrate that newly-synthesized NO donors release nitric oxide in situ and increase myocardial production of prostanoids. NCX 4016 has therapeutic potential because it can be orally administered, lacks hypotensive effects, increases blood levels of nitric oxide and myocardial prostacyclin production.
Systemic lupus erythematosus (SLE) is a complex autoimmune disease that is associated with poor h... more Systemic lupus erythematosus (SLE) is a complex autoimmune disease that is associated with poor health-related quality-of-life outcomes. The objectives of this study were to identify correlates of the domains of the Medical Outcomes Study (MOS) Sleep Scale in SLE and to determine the factors most associated with overall sleep quality. Sleep in 118 SLE patients was assessed using the self-administered MOS Sleep Scale. Bivariate correlations were determined between each of 6 MOS Sleep subscale scores and each sociodemographic, clinical, or psychological predictor variable. Serial hierarchical multiple regression analyses were computed to identify the variables associated with the individual sleep domains and the overall Sleep Problems Index. The MOS Sleep Scale scores of patients with SLE were poorer than the US general population. Depression moderately correlated with 5 (all P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01) and anxiety with 4 subscale scores (all P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.05). The SLE Disease Activity Index did not significantly correlate with any of the subscale scores. Results of a multivariate regression model showed that sleep adequacy and sleep disturbance were independently associated with depression (β = -0.84; 95% confidence interval [CI], -1.37 to -0.32; and β = 0.80; 95% CI, 0.15-1.45; respectively). Daytime somnolence was significantly associated with daily prednisone dosage (β = 0.54; 95% CI, 0.29-0.80) and anxiety trait (β = 0.81; 95% CI, 0.41-1.21). Snoring independently correlated with anxiety (β = 1.64; 95% CI, 0.80-2.29). When demographic, clinical, and psychological variables were simultaneously regressed on the Sleep Problems Index, pain trended toward association with overall sleep problems (β = 0.17; 95% CI, -0.02 to 0.36). Patients with SLE have greater sleep problems relative to the general population. Psychosocial factors, particularly depression and anxiety, are important determinants that are significantly associated with sleep abnormalities in SLE.
The American Journal of Tropical Medicine and Hygiene, 2010
West Nile virus (WNV) was introduced into North America in 1999 and has now become endemic in the... more West Nile virus (WNV) was introduced into North America in 1999 and has now become endemic in the United States with outbreaks each summer and fall. The virus initially spread throughout the eastern parts of the United States and gradually moved westward. In 2008, human WNV cases were reported in 45 states. Most human WNV infections are asymptomatic. 3 Among persons with clinical illness, the features of acute illness range from uncomplicated West Nile fever to neuroinvasive conditions such as meningitis, encephalitis, and acute flaccid paralysis. After acute illness, many persons recover to their previous state of health. However, 20-50% of persons with clinically diagnosed WNV infection report persistent sequelae including somatic symptoms, cognitive and memory problems, depression, and balance and mobility difficulties. Conclusions regarding the duration of such symptoms have been somewhat inconsistent, with several studies reporting persistent symptoms at 6 and 12 months after the acute infection, 4-6, 8, 10, 12, 13 whereas a recent study concluded that nearly all persons with WNV will recover full function within one year after infection. The reasons for variation in clinical outcomes remain relatively unknown. Previous studies suggest that older age, neuroinvasive disease, medical comorbidities, and more recent infection are associated with more clinically severe outcomes. In many of these studies, the clinical outcome was limited to one or two specific signs and symptoms (e.g., neurologic dysfunction, memory test, presence of specific symptom). Our study objectives were to determine the prevalence of long-term symptoms among persons diagnosed with WNV during 2006-2008 and to determine the association of age, sex, neuroinvasive disease status, hypertension or diabetes, and time since acute infection on the most common individual symptoms. Participants were recruited from persons with WNV who were reported to two of the seven district health departments in Idaho during 2006-2008. All persons were classified as having either confirmed (95%) or probable (5%) WNV infections according to standard case definitions that include a positive IgM test result for WNV and a compatible clinical syndrome. In 2006, Idaho had the greatest number of WNV infections in the United States, and the state continued to be among the top 10 in terms of total reported cases in 2007-2008. As part of a larger study designed to study the immunology of WNV infection, health department staff mailed questionnaires to 407 persons with a newly reported diagnosis of WNV infection; 280 persons returned them (response = 69%). We excluded 3 persons whose surveys included more than 50% missing data, and 12 persons who were asymptomatic at baseline diagnosis. Compared with all persons with WNV who were reported to the two district health departments during this period, the survey respondents were slightly more likely to be female (60% versus 51%), but similar in terms of the proportion with neuroinvasive disease (21% versus 21%). All study procedures were approved by institutional review boards at participating universities and the two local health departments. The questionnaires included items that assessed demographic characteristics, presence of diabetes or hypertension, initial severity of illness (e.g., hospitalization), and impact on work. Time since acute infection was calculated as the number of days from the date of disease onset (self-report) to the date that the questionnaire was completed and rounded to the nearest month. Collaborators at the district health departments provided information on neuroinvasive disease status based on epidemiologic investigation and defined according to standardized case definitions. 2 Symptom Measures. The questionnaire assessed 17 promi nent symptoms that have been associated with WNV infection. Specifically, persons were asked to report if they "had any of the following symptoms with your West Nile virus infection". For each symptom reported, persons were asked to "indicate how severe the symptom was (options low/mild, medium, or severe), and "how long did the symptom last", (options = 1-2 days,
Objectives-Characterize radiographic worsening in knee osteoarthritis (KOA) by race and sex over ... more Objectives-Characterize radiographic worsening in knee osteoarthritis (KOA) by race and sex over four years and evaluate the role of established risk factors in observed race/sex differences Methods-Whites (WHs) (694 males, 929 females) and African-Americans (AAs) (92 males, 167 females) at risk for radiographic KOA were eligible. Cox shared frailty models were used to estimate race and sex group differences in radiographic worsening, defined by Kellgren-Lawrence (K-L) and OARSI joint space narrowing (JSN). Mixed effect models for repeated measures were used to estimate race-and sex-specific mean medial and lateral fixed joint space width (fJSW) over four years of follow-up, as well as annual loss of fJSW. Results-Risk of OARSI medial JSN grade worsening was higher among AA males than WH females (HR 2.28, [95% CI: 1.14-4.57]), though adjustment for KOA risk factors attenuated the association. Compared to WH females, WH males had lower risk of K-L grade worsening (adjusted HR 0.75 [95% CI: 0.58-0.96]). Mean baseline medial fJSW (mm) was 6.49 in WH and AA males, 5.42 in WH females, and 5.41 in AA females. Annual change in mean medial fJSW was greater in AA males (-0.19 mm/year) than in other subgroups (-0.09 WH males, -0.07 WH females, -0.10 AA females, p<0.0001). Compared to WHs, AAs had less lateral fJSW at baseline and throughout follow-up. Conclusions-Compared to WHs and AA females, AA males experienced higher risk of medial joint space loss. Controlling for established risk factors attenuated associations between race/sex and disease worsening, suggesting that risk factors such as obesity, history of knee injury, and bony finger joint enlargements largely explain race/sex variations in rates of KOA development and progression.
Knowledge, attitudes and beliefs of White OA patients by willingness to undergo TKR Surgery. (DOC... more Knowledge, attitudes and beliefs of White OA patients by willingness to undergo TKR Surgery. (DOCX 25 kb)
Knowledge, attitudes and beliefs of African-American OA patients by willingness to undergo TKR Su... more Knowledge, attitudes and beliefs of African-American OA patients by willingness to undergo TKR Surgery. (DOCX 25 kb)
ObjectiveWhile opioids are known to cause unintended adverse effects, they are being utilized by ... more ObjectiveWhile opioids are known to cause unintended adverse effects, they are being utilized by a number of patients with osteoarthritis (OA). The aim of this study was to evaluate the association of patient familiarity and perceptions regarding efficacy and risks with opioid medication use for OA.MethodsA total of 362 adults with knee and/or hip OA were surveyed in this cross-sectional study. Patients’ familiarity with and perceptions of benefits/risks of opioid medications were measured to evaluate potential associations with the utilization of opioid medications for OA within the last 6 months. Logistic regression models were adjusted for sociodemographic and clinical variables.ResultsIn this sample, 28.7% (100/349) reported use of an opioid medication for OA-related symptoms in the last 6 months. Those who were on an opioid medication, compared to those who were not, were younger (mean age 62.5 vs 64.8 yrs), were more likely to have a high school education or lower (48.0% vs 35...
To evaluate race and gender variations in complementary and alternative medicine (CAM) use for kn... more To evaluate race and gender variations in complementary and alternative medicine (CAM) use for knee osteoarthritis (OA) (unadjusted and adjusted for demographic and clinical factors).
ObjectivePerceived discrimination is associated with chronic pain and depression and contributes ... more ObjectivePerceived discrimination is associated with chronic pain and depression and contributes to racial health disparities. In a cohort of older adult veterans with osteoarthritis (OA), our objective was to examine how membership in multiple socially disadvantaged groups (cumulative disadvantage) was associated with perceived discrimination, pain, and depression. We also tested whether perceived discrimination mediated the association of cumulative disadvantage with depression and pain.MethodsWe analyzed baseline data from 270 African American veterans and 247 White veterans enrolled in a randomized controlled trial testing a psychological intervention for chronic pain at 2 Department of Veterans Affairs medical centers. Participants were age ≥50 years and self‐reported symptomatic knee OA. Measures included the Everyday Discrimination Scale, the Patient Health Questionnaire Depression Scale, the Western Ontario and McMaster Universities Osteoarthritis Index pain subscale, and de...
Uploads
Papers by Ernest Vina