John S. Richards

Psycho-social aspects of chronic pain in spinal cord injury☆

&NA; The relationship between persistent pain in spinal cord injury and medical‐descriptive, demographic, psychological and familial‐social data was studied. Multiple linear regression and discriminant analysis were used to predict (1) presence or absence of pain; (2) severity of pain; (3) time post‐injury onset of pain; (4) whether or not pain interfered with activities of daily living. The best combinations of predictor variables accounted for only 15 and 19% of the dependent measures pain vs. no‐pain and onset of pain, respectively. The best combinations of predictor variables accounted for 43 and 44%, respectively of the dependent measures severity of pain and whether or not pain interfered with activities of daily living. Higher levels of subjective pain were associated with greater age, higher verbal intelligence, higher levels of anxiety and a more negative psycho‐social situation. Persons who reported pain interfering with activities of daily living were more likely to be older, of higher intelligence, more depressed, clinically rated as experiencing greater levels of distress and immersed in a more negative psycho‐social environment. The importance of psycho‐social variables in the understanding of persistent spinal cord injury pain and the need for prospective studies along these lines are demonstrated.

Association of periodontitis with rheumatoid arthritis: a pilot study.

BACKGROUND Similarities exist in the epidemiology and immunopathogenesis of periodontitis and rheumatoid arthritis (RA), but the associations between their respective disease activities and severities are less well documented. We evaluated the prevalence and severity of periodontitis in United States (U.S.) veterans with RA and their relationship to RA disease activity and severity. METHODS Patients with RA from an outpatient rheumatology clinic were eligible, and patients with osteoarthritis (OA) served as controls. Dentists, masked to the rheumatologic diagnoses, performed periodontal probing and examined dental panoramic radiographs to assess the presence and severity of periodontitis. Associations of periodontitis with RA were examined using multivariate regression, whereas the association of periodontitis with disease-severity measures in RA was examined using the chi(2) test. RESULTS Sixty-nine patients with RA (57 males and 12 females) and 35 patients with OA (30 males and five females) were studied. Moderate to severe periodontitis was more prevalent in patients with RA (51%) than controls (26%) (P = 0.03), an association independent of age, race, smoking, diabetes mellitus, and gender. Patients with RA who were seropositive for rheumatoid factor (RF) were more likely to have moderate to severe periodontitis (59%) than patients who were RF negative (15%) (P = 0.02). Likewise, patients with RA who were positive for the anti-cyclic citrullinated peptide (CCP) antibodies were more likely to have moderate to severe periodontitis (56%) than patients who were anti-CCP negative (22%) (P = 0.01). There were no associations of periodontitis status with other measures of RA disease activity or severity. CONCLUSIONS In a cohort of U.S. veterans, periodontitis was more common and severe in patients with RA compared to patients with OA. Although unrelated to disease activity, the presence of periodontitis in patients with RA was associated with seropositivity for RF and the anti-CCP antibody, which was highly relevant given the associations of these autoantibodies with poor outcomes and disease pathogenesis in RA.

The international spinal cord injury pain basic data set.

Objective:To develop a basic pain data set (International Spinal Cord Injury Basic Pain Data Set, ISCIPDS:B) within the framework of the International spinal cord injury (SCI) data sets that would facilitate consistent collection and reporting of pain in the SCI population.Setting:International.Methods:The ISCIPDS:B was developed by a working group consisting of individuals with published evidence of expertise in SCI-related pain regarding taxonomy, psychophysics, psychology, epidemiology and assessment, and one representative of the Executive Committee of the International SCI Standards and Data Sets. The members were appointed by four major organizations with an interest in SCI-related pain (International Spinal Cord Society, ISCoS; American Spinal Injury Association, ASIA; American Pain Society, APS and International Association for the Study of Pain, IASP). The initial ISCIPDS:B was revised based on suggestions from members of the Executive Committee of the International SCI Standards and Data Sets, the ISCoS Scientific Committee, ASIA and APS Boards, and the Neuropathic Pain Special Interest Group of the IASP, individual reviewers and societies and the ISCoS Council.Results:The final ISCIPDS:B contains core questions about clinically relevant information concerning SCI-related pain that can be collected by health-care professionals with expertise in SCI in various clinical settings. The questions concern pain severity, physical and emotional function and include a pain-intensity rating, a pain classification and questions related to the temporal pattern of pain for each specific pain problem. The impact of pain on physical, social and emotional function, and sleep is evaluated for each pain.

Prevalence of Vitamin D Insufficiency/Deficiency in Rheumatoid Arthritis and Associations with Disease Severity and Activity

Objective. 25-hydroxy-vitamin D (25-OH-D) insufficiency/deficiency is increasingly prevalent and has been associated with many chronic diseases, including rheumatoid arthritis (RA). Our purpose was to define the prevalence and associations of 25-OH-D insufficiency/deficiency in a cohort of US veterans with RA. Methods. Vitamin D status (25-OH-D) was assessed in patients with RA using radioimmunoassay on banked plasma collected at enrollment. Insufficiency was defined as concentrations < 30 ng/ml and deficiency as < 20 ng/ml. Associations of 25-OH-D insufficiency/deficiency with patient characteristics obtained at enrollment were examined using multivariate logistic regression, adjusting for age, sex, season of enrollment, and race. Results. Patients (850 men, 76% Caucasian) had a mean (SD) age of 64 (SD 11.3) years. The prevalences of 25-OH-D insufficiency and deficiency were 84% and 43%, respectively. After multivariate adjustment, both insufficiency and deficiency were more common with anti-cyclic citrullinated peptide antibody positivity and non-Caucasian race, and in the absence of vitamin D supplementation. 25-OH-D deficiency, but not insufficiency, was independently associated with higher tender joint counts and highly sensitive C-reactive protein levels. Conclusion. In a predominantly elderly, male RA population, 25-OH-D insufficiency was highly prevalent. With the increasing adverse health outcomes associated with hypovitaminosis D, screening and supplementation, particularly among minority, seropositive patients with RA, should be performed routinely.

International Spinal Cord Injury Pain Classification: part I. Background and description

Study design:Discussion of issues and development of consensus.Objective:Present the background, purpose, development process, format and definitions of the International Spinal Cord Injury Pain (ISCIP) Classification.Methods:An international group of spinal cord injury (SCI) and pain experts deliberated over 2 days, and then via e-mail communication developed a consensus classification of pain after SCI. The classification was reviewed by members of several professional organizations and their feedback was incorporated. The classification then underwent validation by an international group of clinicians with minimal exposure to the classification, using case study vignettes. Based upon the results of this study, further revisions were made to the ISCIP Classification.Results:An overall structure and terminology has been developed and partially validated as a merger of and improvement on previously published SCI pain classifications, combined with basic definitions proposed by the International Association for the Study of Pain and pain characteristics described in published empiric studies of pain. The classification is designed to be comprehensive and to include pains that are directly related to the SCI pathology as well as pains that are common after SCI but are not necessarily mechanistically related to the SCI itself.Conclusions:The format and definitions presented should help experienced and non-experienced clinicians as well as clinical researchers classify pain after SCI.

Community reintegration and quality of life following spinal cord injury

This report contains a brief overview of issues related to community reintegration and quality of life for persons with spinal cord injuries. Current data from the National Spinal Cord Injury Statistical Center are provided on place of residence, employment, education and marital status after rehabilitation discharge. The health policy implications of these data are discussed along with prospects for continued improvement of long term social outcomes and directions for future research.

Associations of disease activity and treatments with mortality in men with rheumatoid arthritis: results from the VARA registry

OBJECTIVES To examine the all-cause mortality rate and factors associated with mortality in US veteran men with RA. METHODS Men with RA were enrolled and followed until death or censoring. Vital status was ascertained through systematic record review and standardized mortality ratios (SMRs) were calculated using US life tables for men. Multivariate Cox proportional hazards regression was used to examine the independent associations of patient factors including socio-demographics, comorbidity, measures of RA disease activity/severity and medication use with mortality. Measures of RA disease activity and medications were examined as time-varying factors. RESULTS A total of 138 deaths were observed during 2314 patient-years of follow-up (n=1015 patients), corresponding to a crude morality rate of 5.9 deaths per 100 patient-years (95% CI 5.0, 7.0) and an SMR of 2.1 (95% CI 1.8, 2.5). After multivariate adjustment, factors independently associated with higher mortality risk in men with RA included older age, Caucasian race, low body weight, an increased frequency of rheumatology visits, higher ESR and RF concentrations, increased DAS28, subcutaneous nodules and prednisone use. In contrast, MTX use [hazard ratio (HR) 0.63; 95% CI 0.42, 0.96] was associated with ∼40% lower mortality risk. CONCLUSION Mortality rates among US male veterans with RA are more than twice those of age-matched men in the general population. These results suggest that optimizing disease control, particularly with regimens that include MTX and minimize glucocorticoid exposure, could improve long-term survival in this population.

Reliability and validity of the International Spinal Cord Injury Basic Pain Data Set items as self-report measures

Objective:To evaluate the psychometric properties of a subset of International Spinal Cord Injury Basic Pain Data Set (ISCIBPDS) items that could be used as self-report measures in surveys, longitudinal studies and clinical trials.Setting:Community.Methods:A subset of the ISCIBPDS items and measures of two validity criteria were administered in a postal survey to 184 individuals with spinal cord injury (SCI) and pain. The responses of the participants were evaluated to determine: (1) item response rates (as an estimate of ease of item completion); (2) internal consistency (as an estimate of the reliability of the multiple-item measures); and (3) concurrent validity.Results:The results support the utility and validity of the ISCIBPDS items and scales that measure pain interference, intensity, site(s), frequency, duration and timing (time of day of worst pain) in individuals with SCI and chronic pain. The results also provide psychometric information that can be used to select from among the ISCIBPDS items in settings that require even fewer items than are in the basic data set.

The International Spinal Cord Injury Pain Basic Data Set (version 2.0)

Objectives:To revise the International Spinal Cord Injury Pain Basic Data Set (ISCIPBDS) based on new developments in the field and on suggestions from the spinal cord injury (SCI) and pain clinical and research community.Setting:International.Methods:The ISCIPBDS working group evaluated suggestions regarding the utility of the ISCIPBDS and made modifications in response to these and to significant developments in the field. The revised ISCIPBDS (version 2.0) was reviewed by members of the Executive Committee of the International SCI Standards and Data Sets, the International Spinal Cord Society (ISCoS) Executive and Scientific Committees, the American Spinal Injury Association and American Pain Society Boards and the Neuropathic Pain Special Interest Group of the International Association for the Study of Pain, individual reviewers and societies and the ISCoS Council.Results:The ISCIPBDS (version 2.0) is significantly shortened but still contains clinically relevant core questions concerning SCI-related pain. The revisions include an updated SCI pain classification, omission of three questions regarding temporal pain pattern and three pain interference questions. The remaining three pain interference questions concern perceived interference with activities, mood and sleep for overall pain rather than for individual pain problems and are scored on a 0 to 10 scale.

International Spinal Cord Injury Pain (ISCIP) Classification: Part 2. Initial validation using vignettes.

Study design:International validation study using self-administered surveys.Objectives:To investigate the utility and reliability of the International Spinal Cord Injury Pain (ISCIP) Classification as used by clinicians.Methods:Seventy-five clinical vignettes (case histories) were prepared by the members of the ISCIP Classification group and assigned to a category by consensus. Vignettes were incorporated into an Internet survey distributed to clinicians. Clinicians were asked, for each vignette, to decide on the number of pain components present and to classify each using the ISCIP Classification.Results:The average respondent had 86% of the questions on the number of pain components correct. The overall correctness in determining whether pain was nociceptive was 79%, whereas the correctness in determining whether pain was neuropathic was 77%. Correctness in determining if pain was musculoskeletal was 84%, whereas for visceral pain, neuropathic at-level spinal cord injury (SCI) and below-level SCI pain it was 85%, 57% and 73%, respectively. Using strict criteria, the overall correctness in determining pain type was 68% (versus an expected 95%), but with maximally relaxed criteria, it increased to 85%.Conclusions:The reliability of use of the ISCIP Classification by clinicians (who received minimal training in its use) using a clinical vignette approach is moderate. Some subtypes of pain proved challenging to classify. The ISCIP should be tested for reliability by applying it to real persons with pain after SCI. Based on the results of this validation process, the instructions accompanying the ISCIP Classification for classifying subtypes of pain have been clarified.