Christina A. Porucznik

An Analysis of the Root Causes for Opioid-Related Overdose Deaths in the United States

OBJECTIVE A panel of experts in pain medicine and public policy convened to examine root causes and risk factors for opioid-related poisoning deaths and to propose recommendations to reduce death rates. METHODS Panelists reviewed results from a search of PubMed and state and federal government sources to assess frequency, demographics, and risk factors for opioid-related overdose deaths over the past decade. They also reviewed results from a Utah Department of Health study and a summary of malpractice lawsuits involving opioid-related deaths. RESULTS National data demonstrate a pattern of increasing opioid-related overdose deaths beginning in the early 2000s. A high proportion of methadone-related deaths was noted. Although methadone represented less than 5% of opioid prescriptions dispensed, one third of opioid-related deaths nationwide implicated methadone. Root causes identified by the panel were physician error due to knowledge deficits, patient non-adherence to the prescribed medication regimen, unanticipated medical and mental health comorbidities, including substance use disorders, and payer policies that mandate methadone as first-line therapy. Other likely contributors to all opioid-related deaths were the presence of additional central nervous system-depressant drugs (e.g., alcohol, benzodiazepines, and antidepressants) and sleep-disordered breathing. CONCLUSIONS Causes of opioid-related deaths are multifactorial, so solutions must address prescriber behaviors, patient contributory factors, nonmedical use patterns, and systemic failures. Clinical strategies to reduce opioid-related mortality should be empirically tested, should not reduce access to needed therapies, should address risk from methadone as well as other opioids, and should be incorporated into any risk evaluation and mitigation strategies enacted by regulators.

Minimal clinically important differences (MCID) and patient acceptable symptomatic state (PASS) for visual analog scales (VAS) measuring pain in patients treated for rotator cuff disease

BACKGROUND The MCID is the smallest difference in an outcome score which a patient perceives as beneficial. The PASS is the score below which patients consider themselves well. The purpose of this study was to determine the MCID and PASS for a visual analog scale (VAS) measuring pain in patients treated for rotator cuff disease. MATERIAL AND METHODS 81 patients with rotator cuff disease were evaluated after 6 weeks of non-operative treatment with a VAS measuring pain and two transition questions utilized in determining the MCID and PASS. RESULTS The MCID and PASS were estimated to be 1.4 cm (P = .0255) and 3 cm (95% CI - 22.69, 37.31) on a 10 cm VAS measuring pain, respectively. Age (P = .0492) and hand-dominance (P = .0325) affected the MCID while age (P = .0376) and duration of follow-up (P = .0131) affected the PASS. DISCUSSION The MCID and PASS estimates provide the basis to determine if statistically significant changes in VAS pain scores after treatment are clinically important and if the treatment allowed patients to achieve a satisfactory state. LEVEL OF EVIDENCE Level 3; Nonconsecutive series of patients, diagnostic study.

Minimal Clinically Important Differences in ASES and Simple Shoulder Test Scores After Nonoperative Treatment of Rotator Cuff Disease

BACKGROUND The minimal clinically important difference is the smallest difference in an outcome score that a patient perceives as beneficial. The purpose of this study was to determine the minimal clinically important difference in the American Shoulder and Elbow Surgeons (ASES) score and in the Simple Shoulder Test (SST) score for patients treated nonoperatively for rotator cuff disease. METHODS Eighty-one patients with tendinitis or a tear of the rotator cuff were treated with nonoperative modalities. Evaluation with the ASES score and the SST was performed at baseline and at a minimum of six weeks after treatment. At the follow-up evaluation, the minimal clinically important difference was estimated for the two scores with use of an anchor-based approach involving fifteen-item (pain and function) and four-item improvement questions. RESULTS The fifteen-item function and four-item assessments indicated, respectively, that a 2.05-point (p = 0.02) and 2.33-point (p = 0.0009) change in the SST score from baseline represented a minimal clinically important difference. The fifteen-item function, fifteen-item pain, and four-item assessments indicated that a 12.01-point (p = 0.03), 16.92-point (p = 0.004), and 16.72-point (p < 0.0001) change in the ASES score from baseline represented a minimal clinically important difference. Age, sex, initial baseline scores, and hand dominance had no effect on the minimal clinically important differences (p > 0.05). A longer duration of follow-up after treatment was associated with a greater minimal clinically important difference in the ASES score (p < 0.05), although the duration of follow-up had no effect on the minimal clinically important difference in the SST score. CONCLUSIONS Patients with rotator cuff disease who are treated without surgery and have a 2-point change in the SST score or a 12 to 17-point change in the ASES score experience a clinically important change in self-assessed outcome. These minimal clinically important differences can provide the basis for determining if significant differences in outcomes after treatment are clinically relevant.

Children Who Recover from Early Stunting and Children Who Are Not Stunted Demonstrate Similar Levels of Cognition

Stunting is associated with adverse cognitive development in childhood and adolescence, fewer years of schooling, decreased productivity, and reduced adult stature. Recovery from early stunting is possible; however, few studies explore whether those who demonstrate linear catch-up growth experience long-term cognitive deficits. Using longitudinal data on 1674 Peruvian children from the Young Lives study, we identified factors associated with catch-up growth and assessed whether children who displayed catch-up growth have significantly lower cognition than children who were not stunted during infancy and childhood. Based on anthropometric data for children 6-18 mo of age and again for the same children when they were 4.5-6 y of age, we categorized participants as not stunted, stunted in infancy but not childhood (catch-up), stunted in childhood, and stunted in infancy and childhood. Children who had grandparents in the home, had less severe stunting in infancy, and had taller mothers were more likely to demonstrate catch-up growth by round 2. Children who experienced catch-up growth had verbal vocabulary and quantitative test scores that did not differ from children who were not stunted (P = 0.6 and P = 0.7, respectively). Those stunted in childhood as well as those stunted in infancy and childhood scored significantly lower on both assessments than children who were not stunted. Based on findings from this study, policy makers and program planners should consider redoubling efforts to prevent stunting and promote catch-up growth over the first few years of life as a way of improving childrens physical and intellectual development.

Impact of early and concurrent stunting on cognition

Undernutrition is associated with poor cognitive development, late entry into school, decreased years of schooling, reduced productivity and smaller adult stature. We use longitudinal data from 1674 Peruvian children participating in the Young Lives study to assess the relative impact of early stunting (stunted at 6-18 months of age) and concurrent stunting (stunted at 4.5-6 years of age) on cognitive ability. Anthropometric data were longitudinally collected for children at 6-18 months of age and 4.5-6 years of age at which time verbal and quantitative ability were also assessed. We estimate that an increase in concurrent height-for-age z-scores (HAZ) by one standard deviation was associated with an increase in a childs score on the Peabody Picture Vocabulary Test (PPVT) by 2.35 points [confidence interval (CI): 1.55-3.15] and a 0.16 point increase on the cognitive development assessment (CDA) (CI: 0.05-0.27). Furthermore, we report that the estimate for concurrent HAZ and PPVT is significantly higher than the estimate for early stunting and PPVT. We found no significant difference between early and concurrent estimates for HAZ and CDA. Children from older mothers, children whose mothers had higher education levels, children living in urban areas, children who attended pre-school, children with fewer siblings and children from wealthier backgrounds scored higher on both assessments. Cognitive skills of children entering school were associated with early stunting but the strongest association was found with concurrent stunting suggesting that interventions preventing linear growth faltering should not only focus on the under 2s but include children up to 5 years of age.

Risk Factors for Volleyball-Related Shoulder Pain and Dysfunction

To identify risk factors for volleyball‐related shoulder pain and dysfunction.

Surveillance of methadone-related adverse drug events using multiple public health data sources

Healthcare safety and quality surveillance is increasingly conducted by public health agencies. We describe a biomedical informatics method that uses multiple public health data sources to perform surveillance of methadone-related adverse drug events. Data from Utah medical examiner records, vital statistics, emergency department encounter administrative data and a database of controlled substances prescriptions are used to examine trends in state-wide adverse events related to methadone. From 1997 to 2004, population-adjusted methadone prescriptions increased 727%, with evidence to suggest the rise in the methadone prescription rate is for treatment of pain, not addiction therapy. During the same period of time, population adjusted, accidental methadone-related deaths in medical examiner data increased 1770%. Population adjusted methadone-related emergency department encounters rose 612% from 1997 to 2003. Our results suggest that the increase in methadone prescription rates from 1997 to 2004 was accompanied by a concurrent increase in methadone-related morbidity and mortality. Although patient data is not linked between data sources, our results demonstrate that utilizing multiple public health data sources captures more cases and provides more clinical detail than individual data sources alone. Our approach is a successful biomedical informatics approach for surveillance of adverse events and utilizes widely available public health data sources, as well as an emerging source of public health data, controlled substance prescription registries.

Comparing Eccentric Resistance Exercise in Prostate Cancer Survivors On and Off Hormone Therapy: A Pilot Study

To determine the feasibility of an eccentric resistance exercise training protocol in men with prostate cancer and to assess whether men with prostate cancer who are receiving androgen deprivation therapy (ADT) have a blunted effect from the training as compared with prostate cancer survivors not receiving ADT.

Exploring the relationship between chronic undernutrition and asymptomatic malaria in Ghanaian children.

BackgroundA moderate association has been found between asymptomatic parasitaemia and undernutrition. However, additional investigation using the gold standard for asymptomatic parasitaemia confirmation, polymerase chain reaction (PCR), is needed to validate this association. Anthropometric measurements and blood samples from children less than five years of age in a rural Ghanaian community were used to determine if an association exists between chronic undernutrition and PCR-confirmed cases of asymptomatic malaria.MethodsThis was a descriptive cross-sectional study of 214 children less than five years of age from a community near Kumasi, Ghana. Blood samples and anthropometric measurements from these children were collected during physical examinations conducted in January 2007 by partners of the Barekuma Collaborative Community Development Programme.ResultsFindings from the logistic model predicting the odds of asymptomatic malaria indicate that children who experienced mild, moderate or severe stunting were not more likely to have asymptomatic malaria than children who were not stunted. Children experiencing anaemia had an increased likelihood (OR = 4.15; 95% CI: 1.92, 8.98) of asymptomatic malaria. Similarly, increased spleen size, which was measured by ultrasound, was also associated with asymptomatic malaria (OR = 2.17; 95% CI: 1.44, 3.28). Fast breathing, sex of the child, and age of the child were not significantly associated with the asymptomatic malaria.ConclusionsNo significant association between chronic undernutrition and presence of asymptomatic malaria was found. Children who experience anaemia and children who have splenomegaly are more likely to present asymptomatic malaria. Programmes aimed at addressing malaria should continue to include nutritional components, especially components that address anaemia.

Factors influencing the implementation of anterior cruciate ligament injury prevention strategies by girls soccer coaches

Abstract Joy, EA, Taylor, JR, Novak, MA, Chen, M, Fink, BP, and Porucznik, CA. Factors influencing the implementation of anterior cruciate ligament injury prevention strategies by girls soccer coaches. J Strength Cond Res 27(8): 2263–2269, 2013—Women are 3 times more likely to injure their anterior cruciate ligament (ACL) while playing soccer than men. ACL injury prevention programs (IPPs) involving stretching and strengthening drills can reduce the incidence of ACL injury when incorporated into routine training. The rate of implementation among coaches is largely unknown. The purpose of this study was to determine the rate of implementation of ACL IPP, to identify factors that influence implementation, and to acquire information to assist in design dissemination and implementation strategies. Study subjects were coaches of woman soccer players aged 11–22 years in Utah (n = 756). Data were gathered using a Web-based survey followed by a qualitative study in which “best practice coaches”—coaches who met criteria for successful implementation of ACL IPP—were interviewed via telephone. A minority of survey respondents, 19.8% (27/136), have implemented ACL IPP. Factors associated with successful implementation include length of coaching experience and presence of additional support staff such as a strength and conditioning coach or athletic trainer. Best practice coaches (14/136) unanimously agreed on the following: (a) there are performance-enhancing benefits of ACL IPP, (b) education on ACL injury prevention should be required for licensure, and (c) dissemination and implementation will require soccer associations to enact policies that require IPPs. In conclusion, a minority of girls soccer coaches have implemented ACL IPP and those that have do so because they believe that prevention improves performance and that soccer organizations should enact policies requiring ACL injury prevention education and implementation. Efforts to implement ACL IPP should be driven by soccer organizations, emphasize performance-enhancing benefits, and engage additional coaching staff.