Instruments to assess patient-reported safety, efficacy, or misuse of current opioid therapy for chronic pain: a systematic review

The purpose of this systematic review was to summarize and critically appraise research developing or validating instruments to assess patient-reported safety, efficacy, and/or misuse in ongoing opioid therapy for chronic pain. Our search included the following datasets: OvidSP MEDLINE (1946-August 2012), OvidSP PsycINFO (1967-August 2012), Elsevier Scopus (1947-August 2012), OvidSP HaPI (1985-August 2012), and EBSCO CINAHL (1981-August 2012). Eligible studies were published in English and pertained to adult, nonsurgical/interventional populations. Two authors independently assessed inclusion criteria. Each study was evaluated by 2 authors to assess the sources and content of items, types of psychometric tests, their results, and quality of diagnostic accuracy testing, when applicable. Of 1874 citations found in the initial search, we identified 14 studies meeting our inclusion criteria, describing 9 different instruments. Individual items were derived from surveys of content experts, literature reviews, and adapted non-patient-reported items. Misuse-related items were most prevalent (60/144; 42%), followed by safety (47/144; 33%), with efficacy having the fewest items (17/144; 12%). The studies employed a wide variety of psychometric tests, with most demonstrating statistical significance, but several potential sources of bias and generalizability limitations were identified. Lack of testing in clinical practice limited assessment of feasibility. The dearth of safety and efficacy items and lack of testing in clinical practice demonstrates areas for further research.

Combining rapid HIV testing and a brief alcohol intervention in young unhealthy drinkers in the emergency department: a pilot study

BACKGROUND

We sought to determine the feasibility and impact of brief alcohol/ sexual risk reduction counseling with rapid HIV testing in the emergency department (ED).

METHODS

We recruited 18-40 year olds with unhealthy alcohol use, sexual risk behaviors, and negative/unknown HIV status and assessed for differences in their alcohol consumption and sexual risk behaviors at baseline versus 2 months.

RESULTS

Participants (n = 85) were 61% male, mean age 26 years old, 59% white, 92% unmarried, 57% college educated, 45% without a regular doctor, and 80% with an Alcohol Use Disorders Identification Test (AUDIT) score ≥8. All rapid HIV tests were negative. Among the 70 (82%) with follow-up, alcohol consumption decreased with fewer average weekly drinks (23.6 vs. 9.8, p = .003) and binge drinking episodes (2.0 vs. .9, p = .012). Post-intervention, sexual risk decreased, including increased condom use (23% vs. 46%, p = .007). Women had a greater decrease in alcohol use prior to sex compared with men (p = .021 for interaction).

CONCLUSIONS

Alcohol/sexual risk reduction counseling with HIV testing in the ED is feasible and potentially effective for reducing alcohol use and sexual risk behaviors among young unhealthy drinkers.

SCIENTIFIC SIGNIFICANCE

Future randomized controlled trials are warranted to assess efficacy of this intervention, which would provide young at-risk populations with important preventive services, which they may not have access to otherwise.

A qualitative study to inform the development of a video game for adolescent HIV prevention

PURPOSE

To inform the development of an interactive video game focused on behavior change to reduce risk and promote HIV prevention in young minority adolescents.

METHODS

We used qualitative methods guided by community-partnered research principles to conduct and analyze 16 individual interviews and six focus groups with 10-15 year old boys and girls (36 unique participants) at a neighborhood-based non-profit organization serving youth from low-resource neighborhoods.

RESULTS

We identified three recurring themes. Adolescents report protective factors and facilitators to engaging in risk behaviors including: 1) their personal ability to balance the tension between individuation and group membership; 2) the presence of stable mentor figures in their life; and 3) the neighborhood in which they live.

CONCLUSIONS

By conducting a qualitative study guided by community-partnered research principles, we identified themes from our target audience that could be translated into a video game-based intervention, including the storyline and character development. These methods may increase the intervention's efficacy at promoting HIV prevention by making them more tailored and relevant to a specific population.

Patient-reported symptoms on the antiretroviral regimen efavirenz/emtricitabine/tenofovir

Most patients (80-90%) newly diagnosed with HIV are started on the antiretroviral regimen efavirenz, emtricitabine, and tenofovir (EFV/FTC/TDF). Existing studies of patient tolerability, however, are limited. We compared symptom experiences of patients on EFV/FTC/TDF, and the subsequent impact on health-related quality of life, with those of patients on other combination antiretroviral therapy (cART). We conducted a cross-sectional analysis of the Veterans Aging Cohort Study from February 2008 to August 2009 to compare the symptom experiences of patients on EFV/FTC/TDF vs. other cART, unadjusted and then adjusted for treatment characteristics, and comorbid disease severity. We then assessed the association between EFV/FTC/TDF use and health-related quality of life. Among the 1,759 patients in our analytic sample, EFV/FTC/TDF use was associated with fewer symptoms than was other cART. The use of EFV/FTC/TDF was independently associated with health-related quality of life, and this association was at least partially explained by symptom burden.

Patient and provider-reported symptoms in the post-cART era

Prior research has consistently demonstrated that providers often under recognize symptoms. However, this research was limited by the different ways in which patients and providers were asked about the symptoms patients experience. We sought to (1) describe the prevalence of patient-reported symptoms in the post-cART era; (2) identify those patient-reported symptoms which are most strongly associated with health-related quality of life (HRQoL), hospitalization and mortality; and (3) determine whether primary providers recognize symptoms associated with HRQoL, hospitalization and mortality. We conducted a secondary analysis using baseline survey data from the Veterans Aging Cohort Study and determined which patient-reported symptoms correlated with clinical outcomes using regression analyses. Kappa scores were then calculated. HIV-infected patients suffer from a high burden of symptoms in the post-cART era. Nine out of 20 symptoms correlated with clinical outcomes. Providers universally under recognized symptoms and demonstrated poor agreement beyond chance when patient-report was used as the gold standard.

Breast tumor progression induced by loss of BTG2 expression is inhibited by targeted therapy with the ErbB/HER inhibitor lapatinib

The B-cell translocation gene-2 (BTG2), a p53-inducible gene, is suppressed in mammary epithelial cells during gestation and lactation. In human breast cancer, decreased BTG2 expression correlates with high tumor grade and size, p53 status, blood and lymph vessel invasion, local and metastatic recurrence and decrease in overall survival, suggesting that suppression of BTG2 has a critical role in disease progression. To analyze the role of BTG2 in breast cancer progression, BTG2 expression was knocked down in mammary epithelial cells. Suppression of BTG2 enhances the motility of cells in vitro and tumor growth and metastasis in vivo. The effects of BTG2 knockdown are mediated through stabilization of the human epidermal growth factor receptor (HER) ligands neuregulin and epiregulin and activation of the HER2 and HER3 receptors, leading to elevated AKT phosphorylation. Suppression of HER activation using the tyrosine kinase inhibitor lapatinib abrogates the effects of BTG2 knockdown, including the increased cell migration observed in vitro and the enhancement of tumorigenesis and metastasis in vivo. These results link BTG2-dependent effects on tumor progression to ErbB receptor signaling, and raise the possibility that targeted inhibition of this pathway may be relevant in the treatment of breast cancers that have reduced BTG2 expression.

The GPA-dependent, spherostomatocytosis mutant AE1 E758K induces GPA-independent, endogenous cation transport in amphibian oocytes

The previously undescribed heterozygous missense mutation E758K was discovered in the human AE1/SLC4A1/band 3 gene in two unrelated patients with well-compensated hereditary spherostomatocytic anemia (HSt). Oocyte surface expression of AE1 E758K, in contrast to that of wild-type AE1, required coexpressed glycophorin A (GPA). The mutant polypeptide exhibited, in parallel, strong GPA dependence of DIDS-sensitive (36)Cl(-) influx, trans-anion-dependent (36)Cl(-) efflux, and Cl(-)/HCO(3)(-) exchange activities at near wild-type levels. AE1 E758K expression was also associated with GPA-dependent increases of DIDS-sensitive pH-independent SO(4)(2-) uptake and oxalate uptake with altered pH dependence. In marked contrast, the bumetanide- and ouabain-insensitive (86)Rb(+) influx associated with AE1 E758K expression was largely GPA-independent in Xenopus oocytes and completely GPA-independent in Ambystoma oocytes. AE1 E758K-associated currents in Xenopus oocytes also exhibited little or no GPA dependence. (86)Rb(+) influx was higher but inward cation current was lower in oocytes expressing AE1 E758K than previously reported in oocytes expressing the AE1 HSt mutants S731P and H734R. The pharmacological inhibition profile of AE1 E758K-associated (36)Cl(-) influx differed from that of AE1 E758K-associated (86)Rb(+) influx, as well as from that of wild-type AE1-mediated Cl(-) transport. Thus AE1 E758K-expressing oocytes displayed GPA-dependent surface polypeptide expression and anion transport, accompanied by substantially GPA-independent, pharmacologically distinct Rb(+) flux and by small, GPA-independent currents. The data strongly suggest that most of the increased cation transport associated with the novel HSt mutant AE1 E758K reflects activation of endogenous oocyte cation permeability pathways, rather than cation translocation through the mutant polypeptide.

Ankyrin-linked hereditary spherocytosis in an African-American kindred

Mutations of ankyrin-1 are the most frequent cause of the inherited hemolytic anemia, hereditary spherocytosis (HS), in people of European ancestry. Ankyrin-1, which provides the primary linkage between the erythrocyte membrane skeleton and the plasma membrane, has numerous isoforms generated by alternative splicing, alternate polyadenylation, use of tissue-specific promoters, and alternate NH(2) or COOH-termini. Mutation detection in erythrocyte membrane protein genes, including ankyrin, has been a challenge, primarily due to the large size of these genes, and the apparent frequent occurrence of HS-associated null alleles. Using denaturing high-performance liquid chromatography (DHPLC), we screened the ankyrin gene of the proband of a large, three generation African-American kindred with ankyrin-deficient HS. DHPLC yielded an abnormal chromatogram for exon 1. Examination of the corresponding exon 1 sequence in genomic DNA from the proband revealed heterozygosity for a mutation of the initiator methionine (ATG to ATA Met 1 Ile). Coupled in vitrotranscription/translation studies with rabbit reticulocyte lysates demonstrated that the wild-type ankyrin erythroid cDNA initiates only from the known initiator methionine, indicating that the use of alternate initiator methionine is not a mechanism of isoform diversity in erythroid cells. The mutant ankyrin allele, unlike some initiator methionine mutations that utilize downstream codons for translation initiation, was associated with a null allele. This is the first report describing ankyrin-linked HS in an African-American kindred.

A complex splicing defect associated with homozygous ankyrin-deficient hereditary spherocytosis

Defects in erythrocyte ankyrin are the most common cause of typical, dominant hereditary spherocytosis (HS). Detection of ankyrin gene mutations has been complicated by allelic heterogeneity, large gene size, frequent de novo mutations, and associated mRNA instability. Using denaturing high-performance liquid chromatography (DHPLC)-based mutation detection, a mutation in the splice acceptor of exon 17 was discovered in a Turkish family. Reticulocyte RNA and functional minigene splicing assays in heterologous cells revealed that this mutation was associated with a complex pattern of aberrant splicing, suggesting that removal of intron 16 is important for ordered ankyrin mRNA splicing. As predicted by clinical, laboratory, and biochemical studies, the parents were heterozygous and the proband was homozygous for this mutation. These data indicate that DHPLC offers a highly sensitive, economic, and rapid method for mutation detection and, unlike previously suggested, homozygosity for a mutation associated with dominant ankyrin-linked HS may be compatible with life.