Sex and Race Differences in Pain Sensitization among Patients with Chronic Low Back Pain

Growing evidence suggests that chronic low back pain (CLBP) is associated with pain sensitization, and that there are sex and race disparities in CLBP. Given the sex and race differences in pain sensitization, this has been hypothesized as a mechanism contributing to the sex and race disparities in CLBP. This study examined sex and race differences in pain sensitization among patients with CLBP, as well as the role of catastrophizing as a potential mediator of those differences. The study found that compared with men, women required less pressure to produce deep muscle pain and rated mechanical punctate pain as more painful. Compared with non-Hispanic white patients, black patients demonstrated greater pain sensitivity for measures of deep muscle hyperalgesia and mechanical punctate pain. Furthermore, catastrophizing partially mediated the race differences in deep muscle pain such that black participants endorsed greater pain catastrophizing, which partially accounted for their increased sensitivity to, and temporal summation of, deep muscle pain. Taken together, these results support the need to further examine the role of catastrophizing and pain sensitization in the context of sex and race disparities in the experience of CLBP.

Ferumoxytol Is Not Retained in Kidney Allografts in Patients Undergoing Acute Rejection

Purpose

To evaluate whether ultrasmall superparamagnetic iron oxide nanoparticle (USPIO)-enhanced magnetic resonance imaging (MRI) can detect allograft rejection in pediatric kidney transplant patients.

Procedures

The USPIO ferumoxytol has a long blood half-life and is phagocytosed by macrophages. In an IRB-approved single-center prospective clinical trial, 26 pediatric patients and adolescents (age 10–26 years) with acute allograft rejection (n = 5), non-rejecting allografts (n = 13), and normal native kidneys (n = 8) underwent multi-echo T2* fast spoiled gradient-echo (FSPGR) MRI after intravenous injection (p.i.) of 5 mg Fe/kg ferumoxytol. T2* relaxation times at 4 h p.i. (perfusion phase) and more than 20 h p.i. (macrophage phase) were compared with biopsy results. The presence of rejection was assessed using the Banff criteria, and the prevalence of macrophages on CD163 immunostains was determined based on a semi-quantitative scoring system. MRI and histology data were compared among patient groups using t tests, analysis of variance, and regression analyses with a significance threshold of p < 0.05.

Results

At 4 h p.i., mean T2* values were 6.6 ± 1.5 ms for native kidneys and 3.9 ms for one allograft undergoing acute immune rejection. Surprisingly, at 20–24 h p.i., one rejecting allograft showed significantly prolonged T2* relaxation times (37.0 ms) compared to native kidneys (6.3 ± 1.7 ms) and non-rejecting allografts (7.6 ± 0.1 ms). Likewise, three additional rejecting allografts showed significantly prolonged T2* relaxation times compared to non-rejecting allografts at later post-contrast time points, 25–97 h p.i. (p = 0.008). Histological analysis revealed edema and compressed microvessels in biopsies of rejecting allografts. Allografts with and without rejection showed insignificant differences in macrophage content on histopathology (p = 0.44).

Conclusion

After ferumoxytol administration, renal allografts undergoing acute rejection show prolonged T2* values compared to non-rejecting allografts. Since histology revealed no significant differences in macrophage content, the increasing T2* value is likely due to the combined effect of reduced perfusion and increased edema in rejecting allografts.

     

Serotype 10A in Case Patients with Invasive Pneumococcal Disease: A Pilot Study of PCR-Based Serotyping in New Jersey

In 2008, the New Jersey Department of Health (NJDOH) identified a 21.1% increase in reported invasive pneumococcal disease (IPD). In 2009, NJDOH piloted nucleic acid-based serotyping to characterize serotypes causing IPD. From April through September, NJDOH received specimens from 149 of 302 (49%) case patients meeting our case definition. An uncommon serotype, 10A, accounted for 25.2% of IPD overall and was identified in 12 counties, but it was associated with one county (rate ratio = 5.4, 95% confidence interval [CI] 2.1, 11.8). NJDOH subsequently conducted a case-control study to assess the presentation of and clinical risk factors for 10A IPD. Case patients with 10A IPD were more likely to have had immunosuppression, asthma, and multiple chronic medical conditions than control subjects had (odds ratio [OR] = 2.6, 95% CI 1.1, 6.3; OR=4.7, 95% CI 1.7, 13.2; and OR=2.3, 95% CI 1.0, 5.2, respectively). State-based pneumococcal serotype testing identified an uncommon serotype in New Jersey. Continued pneumococcal serotype surveillance might help the NJDOH identify and respond to future serotype-specific increases.Streptococcus pneumoniae (S. pneumoniae) is a leading cause of bacterial pneumonia, bacteremia, and meningitis. In 2008, the New Jersey Department of Health (NJDOH) observed a 21.1% increase in reported invasive pneumococcal disease (IPD) compared with IPD cases reported in 2007 (95% confidence interval [CI] 8.6, 35.2, 8.33 cases/100,000 population in 2008 vs. 6.88 cases/100,000 population in 2007), including increases in four counties. In response, in 2009, NJDOH began a pilot project to characterize the serotypes causing IPD and to determine if serotypes not included in current vaccines contributed to these increases. When our investigation identified an unusual serotype, 10A, NJDOH conducted a case-control study to assess the presentation of and clinical risk factors for 10A IPD.     

A Systematic Review of Randomized Controlled Trials of Interventions to Improve the Health of Persons During Imprisonment and in the Year After Release

We systematically reviewed randomized controlled trials of interventions to improve the health of people during imprisonment or in the year after release. We searched 14 biomedical and social science databases in 2014, and identified 95 studies.Most studies involved only men or a majority of men (70/83 studies in which gender was specified); only 16 studies focused on adolescents. Most studies were conducted in the United States (n = 57). The risk of bias for outcomes in almost all studies was unclear or high (n = 91). In 59 studies, interventions led to improved mental health, substance use, infectious diseases, or health service utilization outcomes; in 42 of these studies, outcomes were measured in the community after release.Improving the health of people who experience imprisonment requires knowledge generation and knowledge translation, including implementation of effective interventions.Worldwide, more than 11 million people are imprisoned at any given time, and the prison population continues to grow at a rate faster than that of the general population.1 Substantial evidence reveals that people who have experienced imprisonment have poor health compared with the general population, as indicated by the prevalence of mental illness, infectious diseases, chronic diseases, and mortality.2There are several reasons to focus on improving the health of people who experience imprisonment.3 The burden of disease in this population affects the general population directly through increased health care costs and through the transmission of communicable diseases (e.g., HIV, HCV, and tuberculosis) after people are released from detention. Imprisonment has also been associated with worse health in family members of those who are detained, compared with the general population, including chronic diseases4 and poor mental health5,6 in adult relatives and mortality in male children.7 At the community level, higher rates of incarceration have been associated with adverse health outcomes, such as sexually transmitted infections and teen pregnancies.8 There is also evidence that poor health in persons who are released from detention, particularly those with inadequately treated mental illness and substance use disorders,3 may affect public safety and reincarceration rates,3 and that better access to health care is associated with less recidivism.9,10 Finally, the right to health and health care is enshrined in international human rights documents,11,12 and is a legislated responsibility of governments in many countries.Intervening during imprisonment and at the time of release could improve the health of people who experience imprisonment and public health overall.13 Knowledge translation efforts, such as syntheses of effective interventions, could lead to the implementation and further evaluation of interventions,14 and identify areas where further research is needed. To date, only syntheses with a limited focus have been conducted in this population, for example, reviews of interventions related to HIV15 or for persons with serious mental illness.16 Decision makers, practitioners, and researchers in this field would benefit from a broader understanding of the state of evidence regarding interventions to improve health in people who experience imprisonment.To address this gap, we systematically reviewed randomized controlled trials of interventions to improve health in persons during imprisonment and in the year after release. We chose this population because we view imprisonment as a unique opportunity to deliver and to link with interventions for this population, and to highlight interventions that could be implemented by those responsible for the administration of correctional facilities. We limited this study to randomized controlled trials, recognizing that randomized controlled trials provide the highest quality of evidence compared with other study designs.17     

Determining Chronic Disease Prevalence in Local Populations Using Emergency Department Surveillance

Objectives. We sought to improve public health surveillance by using a geographic analysis of emergency department (ED) visits to determine local chronic disease prevalence.Methods. Using an all-payer administrative database, we determined the proportion of unique ED patients with diabetes, hypertension, or asthma. We compared these rates to those determined by the New York City Community Health Survey. For diabetes prevalence, we also analyzed the fidelity of longitudinal estimates using logistic regression and determined disease burden within census tracts using geocoded addresses.Results. We identified 4.4 million unique New York City adults visiting an ED between 2009 and 2012. When we compared our emergency sample to survey data, rates of neighborhood diabetes, hypertension, and asthma prevalence were similar (correlation coefficient = 0.86, 0.88, and 0.77, respectively). In addition, our method demonstrated less year-to-year scatter and identified significant variation of disease burden within neighborhoods among census tracts.Conclusions. Our method for determining chronic disease prevalence correlates with a validated health survey and may have higher reliability over time and greater granularity at a local level. Our findings can improve public health surveillance by identifying local variation of disease prevalence.In its 2012 report on measures for population health, the Institute of Medicine prioritized understanding local population health to improve health care for populations with the highest need.1 Generally, health care providers have used the term “population health” when referring to patients linked to a specific health care provider or insurance group.2 However, the discipline of public health more broadly defines population health as the health of all individuals living in specific geographic regions.3To estimate disease burden, traditional methods include performing population-based telephone health surveys.4 Unless large numbers of individuals are surveyed, it is difficult to determine prevalence in small geographic areas such as census tracts, and yearly estimates have significant noise because of small sample sizes.5 Low response rates can lead to errors in estimating disease prevalence, and larger surveys can be costly and difficult to perform.6With increasing use of big data in the form of large administrative data sets with clinical data,7 there is an opportunity to create more precise measures of population health by reducing the variance associated with small sample sizes.8–10 These methods may be biased as they only track individuals who register a medical claim, which makes for a type of convenience sample. Nevertheless, a significant proportion of all individuals, regardless of insurance type, interact with the health care system, especially through emergency services. Nearly 1 in 5 individuals report having gone to an emergency department (ED) in the past year.11 Previous studies have demonstrated the promise of using emergency claims data for tracking acute illnesses; however, there is potential to extend these methods to the surveillance of chronic disease.12,13 One of the advantages of using administrative claims data is the achievement of large sample sizes without the need to conduct large surveys.14,15In this study, we have introduced a novel geographic method of public health surveillance and determined whether we could use ED administrative claims to estimate chronic disease prevalence at a local level over time. As the ED is generally a place where all individuals can access care regardless of socioeconomic or insurance status, it offers an ideal environment for public health surveillance among all types of individuals within a heterogeneous population.16     

Effects of decentralisation and health system reform on health workforce and quality‐of‐care in Indonesia, 1993–2007

The impact of decentralisation, socioeconomic changes and healthcare reforms in Indonesia on type and distribution of healthcare providers and quality‐of‐care has been unclear. We examined workforce trends for healthcare facilities from 1993 to 2007 using the Indonesian Family Life Surveys. Each included a sample of public and private healthcare facilities, used standardised interviews for numbers and composition of staffing, and quality‐of‐care vignettes. There was an increase in multiprovider facilities and shift in profile of solo providers—increasing proportions of midwives and drop in doctors in rural areas (including facilities with doctors) and nurses in urban areas. Quality‐of‐care scores were low, particularly for nurses as solo providers. Despite increased numbers of healthcare workers and growth of the private sector, outer Java‐Bali and rural areas continued to be disadvantaged in workforce capacity and quality‐of‐care. The results have implications for accreditation and in‐service training requirements, the legal status of nurses and private sector regulation. Copyright © 2014 John Wiley & Sons, Ltd.